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Introduction Work is a significant part of people's life. Many organizations have strived to understand the impact of work in the quality of life of workers and their families, organizations, and the quality and safety of care provided. In 2017, the International Labour Organization presented the Safety and Health at Work objective as part of the Decent Work and the 2030 agenda for sustainable development 1 . Recognizing the importance of work-life balance, the Eurofound identifies intensity, regularity, flexible work schedules, support from the administration and colleagues, as cardinal factors for achieving this balance 2 . In 2019, this organization also called attention to the new upcoming challenges concerning increasing ageing of the population and prolonged active life at work worldwide 3 . Similarly, the development and the increasing innovation in eliciting digital technologies have led to labour changes increasing connectedness among workers 4 . All these related factors, such as work overload, work pressure and competitiveness, role conflicts and the unpredictability of events , characterize many of the work environments, with significant impact on family relationships [5][6][7] . Among many other professionals, nurses are often exposed to harmful work environments, and these professionals experience particular situations related to the nature of a highly demanding and stressful profession, both at physical and emotional levels, affecting health, family interaction and quality of care delivery [8][9][10] . The phenomenon of workaholism has also been found in nurses, with high risks for their psychological and physical health [11][12][13] . Workaholism is characterized by obsessive behaviour 14 and literature has put forward some theoretical models aiming to its conceptualization, namely, the Affection-cognition-behaviour 15 , the Role Conflict 16 and the Personality and Inducements 17 . Affection-cognition-behaviour is associated with the dimensions of affection, cognition and behaviour, and is evidenced when the worker enjoys his/her work, experiences some type of anxiety when not engaged in work and is somewhat over-committed, nevertheless, finds it satisfying. The role conflict appears as a facilitator, and according to its authors, workaholism is related to negative well-being and burnout. Finally, the Personality Traits and Inducements model, advocates that workaholism is a result of the interac-tion between personality traits, and personal and organizational inducements. Moreover, some studies point out as consequences of this phenomenon, cardiovascular complications, sleep pattern disorders and increased levels of stress [18][19] , the burnout syndrome and secondary traumatic stress 14,20 , mental health problems 21 and changes in the family relationship [22][23][24] . Early studies on the work-family relationship focused on the difficulties of interaction and the negative side of the conflict 25 . When addressing these multiple inhibiting factors in the management of professional and family roles, Authors called conflict to the negative interaction between work-family and family-work and identified these as related but independent constructs 26 . Moreover, the positive influence of work-family and family-work stems from the contribution of positive psychology. Some examples of this influence are the development of social skills 27 and social recognition 28 . Furthermore, authors identified the integrative perspective of the work-family interaction as a mutual influence, either negative or positive 29 . Although this latter perspective allows broader visibility, the literature has shown a greater predominance of negative relationships in the work-family interaction 30 , associated with the work environment, such as ambiguity and role conflict 31 , burnout 32 , increased use of technology [33][34] , job satisfaction 35 and absenteeism 36 . However, some other factors were found to be related to the family, such as the demand for household chores and the parental role 25,[37][38] . Regarding nurses, the literature suggests the association between family conflict, depression and musculoskeletal disorders 39 , quality of sleep 40 , satisfaction and intention to leave 41 , burnout 30,[42][43] , quality of care delivery 44 , work context 45 and workaholism [46][47][48] . Thus, this study aims to identify the prevalence of workaholism and work-family interaction, their relationship and their variation according sociodemographic and occupational characteristics among nurses. --- Methods --- Study design and Participants A quantitative cross-sectional and correlational study design was used. A convenience sample of Portuguese nurses with time profes-sional experience equal or more than one year was recruited. The Portuguese Order of Nurses supported this study by emailing a newsletter and making available a link to all registered nurses. A total of 839 nurses participated in the study, a valid sample considering the sample size of 729 nurses , for a 95% confidence level, accuracy of 3.25% and expected prevalence of workaholism of 28.3%. Data collection was performed between October and December 2019. --- Instruments For the data collection, a survey was developed, integrating a sociodemographic and professional questionnaire, the Dutch Work Addiction Scale 14,49 to assess workaholism, and the Survey Work-Home Interaction Nijme-Gen [29][30] to identify work-family interactions. The 10-item DUWAS is assessed through a 4-point Likert scale and includes two dimensions: excessive work and compulsive work . According to the authors, participants with scores equal to or higher than the 75th percentile in the combination of compulsive work and excessive work or in the score of addition to work were considered work addicts. 14 SWING integrates 22 items with a 4-point Likert response option ranging from 0-never to 3-always, and four dimensions enabling to assess the work-family relationship in terms of direction and quality of influence . It should be noted that the negative influence expresses the work-family conflict, according to its direction. For each dimension, high scores correspond to high levels of either positive or negative work-family interaction. The reliability of results was assessed through the Cronbach alpha coefficient. The DUWAS scores ranged between α 0.753 and α 0.81, and SWING between α 0.796 and α 0.896 , suggesting acceptable and good internal consistency. 50 These results corroborate those found in validation studies 14,[29][30]49 . --- Data analysis Quantitative analysis of data was performed using the program for statistical and epidemiological analysis of data and Statistical Package for the Social Sciences . Absolute and relative frequencies mean and standard deviation were used for descriptive analysis, as well the Pearson Correlation Coefficient for inferential analysis, and the Stepwise method for multiple linear regression. The statistical significance level was set at 5% . --- Ethical considerations The study was approved by the Ethics Committee of Nursing School of Porto and the Council of the Portuguese Order of Nurses collaborated in disseminating the study on its web page. The nurses willing to participate could access the information on this study through a link made available, which also included informed consent. Upon acceptance, the participants were able to fill the questionnaire. --- Results From the total participants, 82% were women, 63% were married or cohabiting, 61% had children, and were aged on average 38 years , ranging between 21 and 61 years. As for academic qualifications, the majority had an undergraduate degree , followed by a master's degree . The average time of professional experience was 16 years , being 58% of the sample working in hospitals and 25% in primary health care, with a permanent employment contract and shift work . As for the geographical area, the majority of participants were located in the northern region , followed by the centre and south . Concerning the perception of stress related to the professional activity, 90% of respondents considered it stressful and 61% of nurses referred to engaging in after-work leisure activities. The results obtained for workaholism, according to the cut-off point as proposed by authors 14 highlighted a prevalence of 27.1%. Concerning the mean value for dimensions compulsive work and excessive work, moderate values were found, scoring lower for compulsive work and overall workaholism when compared with excessive work . For the work-family interaction , weak and moderate mean values were found for the four dimensions of the scale , with higher mean values for the negative work-family interaction and positive family-work interaction, followed by the positive work-family interaction and the negative family-work interaction. The analysis of correlations showing a positive and moderate association of workaholism, compulsive work and excessive work with the negative work-family interaction, and a very weak association with the negative family-work interaction. 51 Finally, the positive work-family interaction showed only a weak statistical association with excessive work. In sum, the results showed a relatively weak association of workaholism with the family-work interaction in both directions. The Stepwise multiple linear regression was calculated to analyse the variables that best explained workaholism . The sociodemographic and work variables were considered, as well as the dimensions of the Work-Home Interaction Scale. Table 2 displays the variables identified as significant predictors. The data show that workaholism is explained by the relationship of the work-family interaction , occupational variables and sociodemographic variables ; the compulsive work by the relationship of work-family interaction , occupational variables and sociodemographic variables ; and the EW by the relationship of work-family interaction , occupational variables and sociodemographic variables . The linear regression also revealed that the best predictors for workaholism were the variables negative work-family interaction accounting for 38.3% , the perception of stressful work, scoring 7% and gender reaching .7% . As for compulsive work, results showed that the variables negative work-family interaction accounted for 22.5% , the perception of stressful work scored 3.6% and age reached 1.7% . Finally, the higher predictive values for excessive work were found in the variables negative work-family interaction, accounting for 38.3% , the perception of stressful work, scoring 7.9% and gender, reaching 0.7% . Thus, work-family interaction is the best predictive variable for workaholism and its dimensio ns. --- Discussion Regarding the prevalence of workaholism among nurses, the 27.1% score found in this study was higher when compared to that identified in Italian nurses 13 accounting for 21% and 13.7% in Iranian nurses 19 . Concerning workers in management areas, identified a prevalence of workaholism of 9.4% 52 , while in medical residents 16 it was 16% and 29% in a sample of Brazilian workers 53 . Regarding the dimensions of workaholism, they showed a higher mean value for excessive work compared to compulsive work, in line with the results of other study [54][55] . However, in a study with Italian nurses 56 and university academics technical and administrative personnel in Norway 24 , compulsive work scored slightly higher. Considering the work-family interaction, the negative influence expressed in the work-family interaction and the positive family-work interaction were highlighted, corroborating national 30,43 and international studies 57 . Also, authors found higher mean values for the positive influence in both work-family interaction and family-work interaction directions [58][59] . Furthermore, the negative effects of work within the family have been addressed in several studies 15,17 . A negative and weak interaction between workaholism and the negative work-family interaction was also found, much in line with other findings 22,48 . Regarding workaholism and its dimensions, the main predictor found in the present study was the work-family interaction, with a greater negative impact on the negative work-family interaction dimension. This result is in line with the literature, suggesting that the family is one of the variables with higher influence on workaholism 15,[60][61] , associated with the most prominent societal changes with women playing an active role in the labour market and also the reshaping of family and professional role-play 5,62 . Considering occupational variables, only the perception of stress and leisure activities were found to be predictors. However, the impact of stress was found higher and negative compared to leisure activities. These results are in line with the model 15 and the study 63 , who identified stress as one of the antecedents of workaholism. Also, some studies point out to other factors, such as job demands, organizational culture, available resources and work overload 12,18,61 . On the other hand, among the sociodemographic variables, age and gender were found to be significant predictors. However, gender did not show a significant association with compulsive work, much in line with the other findings [64][65][66] . Contrarily, a study suggests that male gender constitutes a risk factor 60 . This study presents as limitations its cross-sectional nature and its online dissemination. However, the study points out some strengths such as the sample size, and insight on the work-family interaction variable in both directions and quality of influence, aiming to explain the workaholism phenomenon in a sample of nurses. --- Conclusions These study findings confirm the existence of workaholism among nurses, showing moderate values, but higher for compulsive work. Considering the work-family interaction, the negative influence expressed by the work-family interaction direction was highlighted, and it was also found to be the best predictor for workaholism, indicating that the higher the negative work-family interaction, the higher workaholism, compulsive work and excessive work. Regarding other predictor variables, workaholism, compulsive work and excessive work were found to be asso-ciated with nurses showing a lower perception of stress and with younger and female nurses, compared to those who reported engaging in leisure activities. Considering these findings, further studies should be undertaken to help better understand the phenomenon in nursing professionals, namely by adding new organizational variables and with a longitudinal character. Moreover, it would be of great interest to integrate these themes into the scope of the nursing degree course. In sum, this study contributes to raise managers' awareness of the importance of work organisation, integrating the family dimension and contributing to the development of programmes to promote health at work. Furthermore, it will likely enhance the work-family-work integration, namely by implementing measures favouring the work-family interaction and enabling the assessment of the impact of the implemented programmes. It is important to notice that work-family balance directive 67 introduces in Europe, since june 2019, a set of legislative actions designed to promote a less conflict with this major current roles of workers' life. Moreover, with sudden events such as COVID-19 pandemic, nurses are suffered increased demand that can lead to workaholism and difficult an adequate balance between work and family. --- Collaborations EMN Borges, CAC Sequeira, MP Mosteiro-Díaz contributed to study design and study supervision. EMN Borges contributed to data collection. Elisabete Borges and CML Queirós contributed to data analysis. EMN Borges, CAC Sequeira, CML Queirós and MP Mosteiro-Díaz contributed to manuscript writing, critical revisions of the important intellectual content, final approval of the version to be published.

Resumo O objetivo deste estudo foi identificar a prevalência da adição ao trabalho, os níveis de interação trabalho-família e a relação destes com características sociodemográficas e laborais em enfermeiros. Estudo quantitativo, descritivo, correcional e transversal numa amostra de 839 enfermeiros de Portugal continental. Relativamente à adição ao trabalho, identificaram-se 27,1% de enfermeiros adictos, com valor médio superior no trabalho excessivo. No que respeita à interação trabalho-família, as dimensões com médias superiores foram a interação negativa trabalho-família e a interação positiva família-trabalho. As variáveis identificadas como preditores significativos da adição ao trabalho foram a interação trabalhofamília (39%), as variáveis laborais (10,6%) e as sociodemográficas (1,2%). Das variáveis laborais e profissionais salienta-se o sexo feminino, idade igual ou inferior a 37 anos e a perceção de trabalho stressante. A confirmação deste fenómeno em enfermeiros, assim como, das variáveis que o podem potenciar, possibilita ao profissional e às organizações, uma maior consciencialização dos seus impactos, nomeadamente na saúde mental incentivando o desenvolvimento de programas que visem a promoção de saúde no local de trabalho.

INTRODUCTION Home renovation is one of the cooperation programs launched to overcome social, economic, and cultural problems as an effort so that underprivileged people can be more empowered and independent through the repair of uninhabitable houses. Home renovation also has an urgency to strengthen harmony between residents by participating in working together to build houses that provide benefits. In fact, Home renovation is present as a solution to reduce poverty levels by providing home improvement services that meet health requirements for beneficiary families, improving the ability to carry out family roles and functions to provide protection, improving the quality of life and family dignity, and developing community participation to be able to work together and prioritize the value of togetherness in the implementation of Home renovation activities that can help economic conditions, so that it becomes a solution to the problem of poverty [1]; [2]; [3]. The implementation of the Home renovation assistance program is certainly included in public policy to provide welfare to the community [4]. In its implementation, public policy refers to the mechanisms, resources, and relationships associated with the implementation of policy programs. The implementation of public policy itself is a clear implementation of what has been determined by policy makers and has a certain impact. Core elements in public policy implementation include: program detail specifications; resource allocation; Decision. The implementation of public policy is also carried out based on certain norms directed towards achieving certain goals [5]; [6]. However, in the midst of Home renovation activities carried out in Cimahi City in 2021, there are many dynamics of problems ranging from pre-Home renovation activities to post-Home renovation. These dynamics vary from misunderstanding of communication to social jealousy among the surrounding community [7]. This starts from the selection of prospective beneficiaries and is selected based on several requirements that have been verified with the suitability of the criteria for recipients of home renovation assistance, continuing with the existence of prospective recipients of home renovation assistance that has been determined, until social jealousy arises from some local residents who doubt prospective recipients. In addition, local residents are also known to contribute less in helping the implementation of the program, even though the urgency of Home renovation is none other than fostering the spirit of mutual cooperation from the surrounding community so as to create a harmonious, just, and prosperous life [4]; [8]; [9]. Based on the facts or realities that occur in the field, further research is carried out on the Home renovation program in Cimahi City which certainly has similarities, differences, and uniqueness compared to previous studies [7], [10]. In this case, researchers take several related studies as comparison material so that the latest research has better results. The first study explains that the process of Home renovation must be participatory which involves the role of local residents in the process. It aims to build social energy that contains unity values through mutual aid activities carried out by local residents. Furthermore, the second study explained that the Home renovation program in Kulonprogo emphasizes the commitment of the Kulonprogo Regional Government and social care from various elements of society to help fellow poor people in meeting the basic needs of houses. In this case, the government makes a special budget to be allocated as a fund for the construction of Home renovations so that the program can be carried out properly and optimally. In addition, just like the previous study, the second study also emphasizes the aspect of mutual assistance to increase public awareness to work together to improve social welfare in their environment. Finally, the third study emphasizes more on the aspect of processing information data for recipients of home renovation programs so as not to be mistargeted using Data Mining. This is so that later the government can be more selective in choosing aid recipients objectively so as to reduce the emergence of misunderstandings and social jealousy that often trigger violence between surrounding communities [11], [12]. Copyright © 2023, Jurnal Ilmu Sosial Mamangan| 183 Based on the three previous research results, there are several similarities with the current Home renovation research in Cimahi City, namely in emphasizing the value of mutual assistance involving the surrounding community as participants for the smooth running of the Home renovation program and the selection of prospective beneficiaries appropriately in accordance with predetermined criteria. In addition, there is also a uniqueness that distinguishes the Home renovation program in Cimahi City from the Home renovation program based on previous research, namely the collaboration with architects where later the houses built have excellent quality and adequate facilities by prioritizing their function as habitable homes, healthy homes, and of course not forgetting the aesthetic value or beauty of the houses built. This aims to add comfort value for recipients of Home renovation assistance so that the house obtained does not look built carelessly and does not require re-repair after occupancy . Therefore, the urgency of this research based on the exposure of previous theories and research is that it is hoped that the Home renovation program that has been launched by the government does not cause excessive social jealousy among residents. Thus, the government must be more selective in determining the right prospective citizens to be included in the home renovation assistance program. This is because the program is recognized very well and certainly has a positive impact on poverty alleviation, so that it will sustainably bring prosperity in people's lives. In terms of research objectives, the formulation of research problems / problems can be described as follows: Describe the form of the Home renovation program in Cimahi City, and Describe conflict resolution efforts in relation to the Home renovation program in Cimahi City. . --- RESEARCH METHODS The method used in this study is qualitative method. This method aims to understand and provide interpretation of the meaning of an event of human behavior interaction in a particular situation according to the researcher's point of view and is carried out in Settings natural or within reasonable limits. Qualitative research itself aims to understand the object under study in depth [18], [19]. While the approach used in this study uses a case study approach. One of the most popular types of qualitative descriptive research is in the form of research with the case study method. This research focuses intensively on one particular object that is studied as a case. The case study method allows researchers to remain holistic and significant. As a case study, the data collected comes from various sources and the results of this study only apply to the case under investigation. For research with a qualitative approach, the unit of analysis is basically a group of people to be researched. In this study, the unit of analysis as The research subjects were beneficiaries of Home renovation in Padasuka Village, Central Cimahi District, Cimahi City [20]. This study highlights several things done in the process of Home renovation in Cimahi City. Based on literature studies, data collection can be done in various settings, various sources, and various ways. When viewed in terms of data collection methods or techniques, data collection techniques can be done by observation, interview, documentation, or a combination of the three. Referring to this, researchers conducted direct observations and interviews in the field where the development process took place, namely in Padasuka Village, Central Cimahi District, Cimahi City. The research team observed what were the obstacles in the process of building Home renovations in terms of human resources, building materials, and the support of government officials and the surrounding environment. In addition, researchers also conducted an interview process with two selected speakers, namely the head of RT 06 Padasuka Village, Central Cimahi District, Cimahi City, and the Head of the West Java 2021 Task Force Health Office to provide strengthening of research results. In the interview process, researchers adapt short, concise, and clear questions, and clarify some doubts by repeating questions, so that the interviewees can provide good and clear responses for the smooth running of the research process [18]. --- RESULTS AND DISCUSSION --- Form of Home renovation Program in Cimahi City In society, there are various social problems that are experienced by all levels of society, especially the lower classes of society. This problem is synonymous with the problem of eligibility and livelihood, especially for poor families. Various solutions are always thought of and sought by the government or local officials, one of which is by launching a Home renovation program [21], [22]. The Home renovation program was prepared as a form of assistance from the West Java Mobile Cimahi City organization, which collaborates with the Cimahi City government and is aimed at poor people with uninhabitable housing quality. This is done so that poor people can have livable houses and improve the quality of settlements in Cimahi City. In its implementation, of course, the initiator of the program must classify the criteria for uninhabitable houses that can be handled in the assistance. The criteria for uninhabitable houses that have been determined are as follows: 1. Frame and walls of the house that are not suitable so that they are unable to provide protection to the occupants of the house 2. It has a fragile roof structure and endangers the occupants of the house. For example, there are leaks and collapses 3. Floor area that is still in the form of soil, not tiles or smooth shafts 4. Poor air ventilation, does not indicate the criteria of a healthy home 5. Unmet aspects of utility 6. Absence of bathing, washing, latrine and landfill facilities After conducting the classification process of uninhabitable houses, the Cimahi City government and the West Java Mobile organization conducted an observation process to select residents who were declared eligible as recipients of program assistance. This search process is carried out with serious observation so that later it is not mistargeted and the benefits of assistance can be felt well by the recipient [23], [24]. After there are two heads of families in Padasuka Village, Cimahi City as prospective beneficiaries in accordance with the criteria previously set, the development process is carried out. Because the Home renovation program in Cimahi City is an assistance program, the involvement of the surrounding community is needed. The reason is, the aid budget is not enough if it is fully carried out by the building manager as a whole. The assistance needed from the community includes physical energy assistance ranging from house demolition, house construction, to cleaning the house and around the yard until it is ready for occupancy [25]; [26]. Before carrying out the Home renovation process, the demolition process of the house to be repaired is first carried out, for example the roof or wall of the house. When carrying out the demolition process, physical personnel are needed, both to dismantle and lift heavy demolition materials. If it does not involve the community in the demolition process, then the implementation of the Home renovation program in Cimahi City will be very heavy. In implementing this program, residents are expected to help by working according to their abilities and equipment used. Residents who do not bring equipment are allowed to help with anything they can. From this process, it can be ascertained that they provide labor assistance as much as possible to be able to realize a planned house intended for their neighbors who need such assistance. The existence of this spirit of mutual assistance is considered extraordinary because in addition to having adequate physical energy capabilities, the community also has a high spirit of solidarity to strengthen integration and help each other [27]; [28]. --- Social Jealousy Conflict Jealousy is defined as a metamorphic compound emotion that includes a summary of feelings. The existing literature suggests that the diverse traits of jealousy have not been fully defined and are still vaguely conceptualized. However, the concept of jealousy can be broadly described as a perceived or real threat to the loss of a valuable relationship. It can also be understood as an emotional response to a perceived threat, where in many cases, the relationship is mainly romantic or sexual in nature. [23], [29]; [30]. Jealousy is also characterized as behavioral , cognitive dimensions , and affective , this can also be felt in broader aspects such as social jealousy in society which is characterized by gaps or distances from social inequalities that occur. There are several effects that occur from social jealousy, including: 1. The birth of stereotypes or stigma given to a group of people and cause anxiety for the recipient of the stigma. 2. Triggers for the birth of social conflicts in society, 3. Conflict of discrimination that is inherent and detrimental to the community and the surrounding environment [31]- [33]. From this statement, the existence of a Home renovation program in fact not only has a positive impact on the living standards of beneficiary families, but also has a negative impact on the jealousy felt by the local community towards the beneficiary residents. Related to that, it can be seen that one way to determine the beneficiaries of the Home renovation program is to look at criteria such as whether the house is its own house that still has dirt floors, and the walls and roof are made of materials that are not suitable for home material. For this reason, the government must be more selective in sorting out which citizens are entitled to assistance. Because in previous studies, it has been explained that the Home renovation program is an effort to alleviate poverty with the aim that the beneficiaries have a decent place to live and can meet the needs of their families [34], [35]. --- The Relationship between Social Jealousy Conflict and Home renovation Program in Cimahi City The conflict of social jealousy based on a sense of unfairness will cause an attitude of comparing the life of the perpetrator with the lives of others. This also happens when there is a Home renovation program, Home renovation itself is a form of assistance from the Cimahi City government in collaboration with community organizations and is intended for underprivileged people with uninhabitable housing quality. This Home renovation program is in great demand by the community because it is undeniable that a livable house is a dream for every individual. Social jealousy can be observed directly in the field, it can be in the form of protest movements and subtle criticisms carried out by the surrounding community. In addition, social jealousy can also be identified indirectly by rumors or rumors circulating among the public [36], [37]. The causes of social jealousy conflicts against the Home renovation program in Cimahi City are based on the following: --- The emergence of social jealousy The implementation of the Home renovation program in Cimahi City is still uneven to local residents, judging from the large amount of data obtained about prospective beneficiaries, there are still many who have not received the Home renovation program because of the achievement indicators that must be met administratively, such as the completeness of land certificates, no disputes, and identity cards that must be appropriate. Communities, especially those who register for the Home renovation program, usually have to wait first and have to be patient because there are at least two prospective beneficiaries who apply for the Home renovation program in each pillar of society, so social jealousy arises when there are approved beneficiaries but the distribution is still uneven [38], [39]. --- Imperfect socialization Before dismantling, program organizers must conduct socialization to the community of the Home renovation environment, to government parties, such as RWs, RTs, urban villages and community leaders. This must be realized so that the implementation of the home renovation program runs well and each element can synergize with each other to succeed the home renovation program. However, over time there are still obstacles that occur in the field. For example, there are still misconceptions between the organizers of Home renovations, villages, and also local residents. The misunderstanding was motivated because many residents did not attend or did not participate in the Forum Goes Discousen when the organizers explained the theme and concept of the Home renovation program, so that at the time the activity was carried out, some residents still questioned the concept of Home renovation, such as water disposal. In fact, in the Forum Goes Discousen regarding waterways, it has been explained which disposal will be flowed. Based on considerations of the surrounding environment, such as houses that are not neatly arranged and tend to protrude downward, organizers must think hard about how the houses of residents under the beneficiaries' houses will not be exposed to water and cement or soil channels when construction is carried out [40]. This imperfect socialization often causes social jealousy where the beneficiary's house is considered more maintained than other residents' homes. Therefore, the socialization process can be said to be the most important thing because similar events are feared to occur. Furthermore, this misunderstanding can certainly make the development process hampered, the RAB design cost is also wrong because some things do not go well according to the schedule that has been designed and also determined [41], [42]. --- Efforts to Resolve Conflicts in Home renovation Program in Cimahi City In every problem that arises during the Home renovation process, of course, there are solution efforts made for the smooth running of the program. Some of the problems that most often arise during the Home renovation process are lack of socialization and increasing social jealousy in the surrounding community. This can be overcome by persuasive methods to local residents, so that the problem of imperfect socialization and social jealousy can be resolved [7], [43], [44]. Some forms of persuasive efforts in conflict resolution that arise during the home renovation program are as follows: a. Persuasive in socialization Before carrying out the Home renovation program activities, Forum Goes Discousen must be held as a means of introduction between program organizers, RT/RW, village government, and surrounding residents for the smooth running of the event to be carried out. In the forum, program organizers must also explain the theme and concept of activities, especially related to the contribution of local residents which are carried out in a mutual cooperation manner to create an atmosphere of mutual assistance. However, judging from the events on the ground, in the Forum Goes Discousen , often many residents did not attend, so there were often misunderstandings about the theme and concept of the Home renovation program. This of course hampers the process of working on the program. [45]- [47]. However, there is a solution offered, which is in the form of direct solution efforts by holding persuasive socialization where organizers and beneficiaries will visit the homes of local residents first to get to know, ask, and ask for blessings and permits to build houses because it will interfere with infrastructure in the area. Thus, it is also a persuasive means to invite local residents to work together in the success of the Home renovation program. --- b. Persuasive in professionalism The home renovation program is a fairly large activity because it involves many elements in it, so this program is highly demanded to be managed professionally. In carrying out its duties and functions, each element involved will greatly affect the progress and results of Home renovation activities. These elements can be identified as program organizers, RT/RW, kelurahan, local residents, and also beneficiaries. Due to the lack of effectiveness of Forum Goes Discousen , there is a re-invitation for socialization accompanied by persuasive professionalism by inviting all elements to be involved in Home renovation activities in accordance with their respective functions and duties. Not only implied, this is also expressed through a Memorandum of Understanding so that Home renovation activities can run smoothly in accordance with a strong basis looking at the guidelines listed in the Memorandum of Understanding earlier [48]- [50]. Thus, misunderstandings and various other obstacles can be overcome. Therefore, in this case, the role of RT / RW is needed in the mediation process related to Home renovation conflicts between aid recipients and surrounding residents. Conflicts often cause obstacles during the program implementation process, so efforts to resolve them must be carried out optimally and professionally. --- c. Carrying out local culture This Home renovation program is located in Cimahi City, West Java. Jawab Barat is a province that is famous for its Sundanese customs or culture, and Cimahi City is Copyright © 2023, Jurnal Ilmu Sosial Mamangan| 188 included in the scope of West Java province which is automatically familiar with Sundanese culture. This is a point that we must pay attention to because culture regarding values and norms is very close to the lives of the surrounding community, so we must be able to adapt in that culture by implementing it. With this method, all forms of activities related to the program must be carried out with the permission of residents or the surrounding community. All forms of licensing are carried out starting from receiving the beneficiary's family, then placing goods, and informing the day, date, and month after the Home renovation is completed. This is also a form of respect for residents or surrounding communities to minimize conflicts that will occur [1], [51], [52]. --- CONCLUSION The Home renovation program in Cimahi City is a form of assistance program from the West Java Mobile Cimahi City organization in collaboration with the Cimahi City government and is intended for poor people with uninhabitable housing quality. This is done with the aim that poor people can have livable houses and can improve the quality of residential areas in Cimahi City. The first step in implementing this program is to carry out the process of classifying uninhabitable houses first, then an observation process is carried out on residents who are said to be eligible as recipients of program assistance, after determining two heads of families as recipients of assistance in accordance with predetermined criteria, finally the construction process can be carried out. Furthermore, the conflict of social jealousy can be interpreted as a feeling that arises and is characterized by a gap or distance from social inequality that occurs in the surrounding environment, which in turn can harm the community and the surrounding environment. The conflict of social jealousy based on a sense of unfairness will cause an attitude of comparing the life of the perpetrator with the lives of others. In the implementation of the Home renovation program, social jealousy can be directly observed in the field through protest movements and subtle criticism from the surrounding community who are jealous of the beneficiary families. In addition, social jealousy can also be identified indirectly by rumors or rumors circulating among the public. Therefore, efforts that can be made to resolve the conflict include conducting persuasive socialization, persuasive in professionalism, and carrying out local culture. This research needs to be refined again from all aspects so that future research that discusses the conflict of social jealousy in the home renovation program can be known in more detail, especially related to the appropriate efforts made in addition to the three efforts previously described. This is so that the Home renovation program can run smoothly and not cause social jealousy of the surrounding community.

Home renovation is a program to improve the homes of residents who are less livable to become livable. In its implementation, in the process of collecting and selecting houses for people who are entitled to receive this assistance, it often requires accuracy to get suitable prospective beneficiaries so that accuracy is needed to be right on target. This study was conducted to determine how the relationship between social jealousy conflict and the process of Home renovation assistance program in Cimahi City. The implementation of the program was carried out by the Cimahi Mobile West Java City organization in collaboration with the Cimahi City government which was carried out in Padasuka Village, Central Cimahi District, Cimahi City. The process of building Home renovations is carried out in a participatory manner with the help of the surrounding community. This research was conducted with qualitative methods through a case study approach with a data collection process using observation techniques, direct observation in the field, and interviews with two resource persons. The results of this study are in the form of efforts to overcome social jealousy so that there is no prolonged conflict in society. For this reason, efforts that can be made in resolving conflicts in the construction of Home renovations in Cimahi City are by conducting persuasive socialization, persuasive in professionalism, and carrying out the culture of the surrounding area. The novelty of this research is overcoming conflict based on tolerance.

INTRODUCTION Gender, as a fundamental social construct, influences every facet of human life, shaping identities, roles, and interactions within societies . The intricate interplay between societal norms, power structures, and cultural influences has engendered a diverse landscape of gender realities that are often veiled beneath the surface . In light of the growing recognition of gender's pivotal role in shaping individual experiences and social structures, this article endeavors to embark on an in-depth analysis of gender dynamics. By delving into the complexities of how gender operates within various contexts, this study aims to uncover the multifaceted dimensions of gender realities and shed light on the underlying mechanisms that influence behaviors, perceptions, and opportunities . As societies progress and evolve, gender-related discussions have gained momentum, bringing to the forefront issues such as gender equality, representation, and violence. Yet, a comprehensive understanding of the nuanced interplay between gender constructs, power dynamics, institutional norms, and cultural influences remains a critical endeavor . This article stands as a response to the pressing need for an expansive exploration of gender dynamicsone that transcends conventional narratives and delves into the less visible realms of gender interactions. By employing a multidimensional approach that acknowledges the intersectionality of gender with other dimensions of identity, including race, class, and sexuality, this analysis aims to illuminate the complexity of gender realities that often defy simplistic categorizations . This study recognizes that the exploration of gender dynamics extends beyond academic inquiry; it has implications for policy, advocacy, and social change. To craft effective strategies that address gender-based inequalities and discrimination, it is imperative to unravel the intricate tapestry of gender's influence on personal lives and societal structures. By unveiling the hidden intricacies of gender dynamics, this research seeks to contribute to a deeper comprehension of the challenges faced by individuals across the gender spectrum, ultimately fostering more informed conversations, evidence-based policies, and a more equitable world . The concept of gender, far from being confined to binary categorizations, exists along a spectrum, encompassing diverse identities, expressions, and experiences. The conventional understanding of gender as a simple dichotomy has been challenged by evolving societal awareness, acknowledging the need for a more inclusive and nuanced perspective. This study recognizes that gender dynamics are not static, but fluid and contextual, influenced by historical legacies, cultural contexts, and socio-economic structures . While progress has been made in addressing gender disparities, persistent inequalities persist. These inequities are deeply rooted in deeply ingrained gender norms and power imbalances that permeate institutions, policies, and everyday interactions. This investigation seeks to unravel these intricate threads that form the fabric of gender dynamics, unveiling the often hidden and subtle mechanisms that perpetuate these disparities. By examining the complexities of gender dynamics, we aim to contribute to a more profound understanding of the lived experiences of individuals and communities, facilitating a more empathetic and informed approach to fostering gender equality . As we delve into this exploration, it becomes evident that gender is not isolated; it intersects with other aspects of identity and inequality. Marginalized groups often face compounded discrimination due to the intersections of race, class, and gender, making the study of gender dynamics an essential step towards dismantling systemic oppression. Through this investigation, we strive to bridge the gap between academic discourse and real-world impact, offering insights that can inform policy decisions, advocacy initiatives, and transformative social change. In the subsequent sections of this article, we present a comprehensive framework for analyzing gender dynamics, drawing on interdisciplinary perspectives and methodologies . Our analysis is grounded in the understanding that unraveling gender realities requires a multifaceted approach, acknowledging both the visible manifestations and the underlying structures that perpetuate gender norms and disparities. By exploring these dimensions, we aim to contribute to a more holistic understanding of the complexities of gender dynamics and advance the discourse surrounding gender equality and social justice. Gender dynamics, as a fundamental aspect of social structures, play a profound role in shaping individuals' lives and societal norms. In the diverse and intricate landscape of India, where traditions, cultures, and socioeconomic contexts intermingle, understanding the multifaceted nature of gender realities becomes particularly crucial. This article embarks on an in-depth analysis of gender dynamics within the Indian context, aiming to illuminate the complexities, challenges, and opportunities that define gender relations and identities in this diverse nation. India, known for its rich cultural tapestry, is also a country grappling with deeply rooted gender inequalities. The complexities of gender dynamics extend beyond mere biological distinctions, encompassing cultural norms, historical legacies, and contemporary shifts. This study seeks to unveil the nuanced interplay between these factors, delving into the myriad ways in which gender influences roles, expectations, and power dynamics within Indian society. In a country characterized by its diverse ethnicities, languages, and traditions, gender dynamics are influenced by regional variations and historical contexts. While there have been advancements towards gender equality, persistent challenges such as gender-based violence, unequal access to education, and limited political representation continue to shape the gender landscape in India. As such, this study aims not only to reveal the existing gender realities but also to provide a comprehensive understanding of the factors that perpetuate or challenge gender disparities . Recognizing the intersectionality of gender with other dimensions of identity, such as caste, class, and religion, is crucial. These intersections further complicate the dynamics of gender relations, often leading to compounded discrimination and marginalized experiences. By adopting an intersectional lens, this analysis seeks to untangle the intricate threads that weave together the tapestry of gender experiences in India. By uncovering the layers of gender dynamics, this research contributes to a more informed dialogue and evidence-based policymaking. As India continues to strive for progress and equality, an exploration of gender realities is essential to address deeply ingrained inequalities and foster a more inclusive and equitable society. Through this examination, we aim to deepen our comprehension of gender dynamics within the Indian context, providing insights that inform both academic discourse and practical interventions. --- B. METHOD This study adopts a qualitative research design to conduct an in-depth analysis of gender dynamics within India. Qualitative research is chosen for its capacity to explore the intricate aspects of gender realities. Semi-structured in-depth interviews and focus group discussions are conducted with a diverse sample to capture a range of perspectives. Thematic analysis is employed to identify recurring patterns and themes in the data, facilitated by NVivo software. Ethical guidelines are followed, obtaining informed consent and ensuring confidentiality. Researchers' reflexivity is acknowledged, and limitations include contextual and interpretation biases. This qualitative approach aims to unravel the complexities of gender dynamics, providing comprehensive insights into cultural norms, power relations, and individual experiences shaping gender realities in India. --- C. RESULT AND DISCUSSION The process of thematic analysis delved into the rich tapestry of narratives from diverse participants, uncovering a spectrum of insights that collectively illuminate the multifaceted and often paradoxical gender dynamics deeply embedded in India's societal fabric. As the data was meticulously examined, five overarching themes emerged, each offering a window into the complex interplay of cultural norms, power dynamics, and individual experiences that intricately shape gender realities within the nation. 1. Cultural Perceptions and Gender Norms: The participants' voices resonated with a consistent theme underscoring the profound influence of cultural norms on gender identities and roles. These deeply ingrained norms perpetuate distinct expectations for men and women, often confining them within predetermined roles that restrict opportunities and reinforce unequal power dynamics. Narratives unveiled the tug-ofwar between tradition and progress, as individuals grapple with the juxtaposition of longstanding norms against modern aspirations. 2. Intersectionality of Identity: The vivid mosaic of gender dynamics is further nuanced by the intersection of gender with other dimensions of identity. Participants emphasized how factors like caste, class, and religion intersect with gender, shaping unique experiences and magnifying inequalities. The narratives poignantly revealed that these intersections, while often ignored, have profound implications, leading to layered discrimination and impacting access to resources and opportunities. 3. Evolving Masculinities and Femininities: The research unfurled the evolving perceptions of masculinity and femininity, signaling a shifting socio-cultural landscape. Traditional definitions of gender roles are gradually making way for more fluid expressions of identity. However, this evolution is not without resistance, as traditional notions of gender are deeply entrenched. The narratives provided insight into the tension that arises when these progressive shifts challenge deeply rooted conventions. 4. Educational Empowerment: Amid the complexity, education emerged as a beacon of change and empowerment. Narratives highlighted how education offers a platform to challenge gender norms, empowering women and marginalized groups to pursue opportunities beyond traditional boundaries. Yet, a stark dichotomy emerged-while education is seen as a powerful tool for change, disparities in educational access persist, particularly in rural areas, where the transformative potential of education remains unrealized. 5. Gender-based Violence and Discrimination: The themes of gender-based violence and discrimination reverberated throughout the narratives, emphasizing the pervasive nature of abuse. Participants shared heart-wrenching stories of harassment, unequal treatment, and systemic barriers that reinforce gender inequalities. The narratives laid bare the urgency of addressing the systemic and cultural factors perpetuating genderbased violence and discrimination. Beyond these focal themes, cross-cutting insights intertwined with the broader analysis. The impact of media in shaping and challenging gender stereotypes emerged as a dual-edged sword. While media can promote progressive ideals, it can also perpetuate harmful norms. Additionally, the discussions on policies and legal frameworks highlighted a complex landscape of opinions on their effectiveness, underlining the need for comprehensive strategies that encompass both systemic reform and cultural change. The rich tapestry of themes and cross-cutting insights collectively underscores the intricacies of gender dynamics within the Indian context. The intersectionality of identity adds layers of complexity, magnifying the challenges faced by marginalized communities. The evolving definitions of masculinity and femininity reflect a society in transition, where progress coexists with resistance. Cultural norms were revealed as both influential and constraining, emphasizing the need for cultural change alongside policy reform. Education's transformative potential and the pressing concerns of gender-based violence and discrimination together represent a call to action. This comprehensive exploration challenges policymakers, advocates, and society at large to address deeply ingrained inequalities and work towards a more inclusive and equitable future. --- Social Interaction and Community Engagement In the rapidly urbanizing landscape of India, where concrete jungles often dominate the horizon, the significance of green spaces transcends mere aesthetics. Beyond providing environmental benefits, green spaces serve as crucial platforms for fostering social cohesion, nurturing a sense of community, and cultivating a shared sense of belonging. This segment of the study delves into the intricate ways in which green spaces facilitate social interactions, encourage community bonding, and engender a deep-rooted sense of belonging among individuals across diverse walks of life. Green spaces, ranging from parks and gardens to community squares, stand as communal havens that draw people from various backgrounds. They act as natural magnets, offering a neutral ground for individuals to converge, communicate, and engage in a myriad of activities. This phenomenon is particularly pronounced in densely populated urban areas, where green spaces become a respite from the hustle and bustle of city life, allowing residents to connect on a human level. The verdant expanse of green spaces provides a canvas for fostering connections beyond individual identities. Picnics, group exercises, cultural events, and impromptu gatherings become catalysts for forging bonds among neighbors who might not otherwise cross paths. These spaces dissolve social barriers, facilitating interactions between generations, economic classes, and cultural backgrounds. As community members engage in shared activities and collaborate on various initiatives, a sense of collective identity emerges, knitting together a fabric of unity that transcends differences. Perhaps most notably, green spaces nurture a profound sense of belonging among those who frequent them. The communal ownership of these areas fosters a feeling of stewardship and responsibility, strengthening ties between individuals and the land they share. Green spaces often become canvases for community expression, where murals, sculptures, and gardens serve as testaments to collective identity. This sense of belonging extends beyond the immediate vicinity of the green space, fostering a ripple effect that contributes to broader social cohesion within neighborhoods and even entire cities. The role of green spaces in promoting social interactions and community bonding is especially significant in the context of India's diverse cultural landscape. These spaces serve as platforms where cultural celebrations, performances, and festivals unfold, allowing people to share their heritage with one another. This cultural exchange enhances understanding and appreciation among diverse groups, thereby fostering an environment of inclusivity and mutual respect. --- Recreational Opportunities: Assessing the Impact of Availability of Recreational Activities on Social Engagement in India In the dynamic cultural milieu of India, where social interactions are deeply woven into the fabric of daily life, the presence and accessibility of recreational opportunities play a pivotal role in shaping the vibrancy of communities. This segment of the study scrutinizes the spectrum of available recreational activities and their influence on fostering social engagement, connecting individuals across diverse backgrounds, and contributing to the collective wellbeing. India's recreational landscape is a tapestry woven from diverse threads, encompassing both traditional and contemporary activities. From traditional dance forms and religious celebrations to modern sports and entertainment, the array of options reflects the multifaceted nature of the nation's interests. Festivals, community events, sports tournaments, cultural workshops, and outdoor adventures serve as canvases for shared experiences, where people congregate to celebrate, compete, and connect. Recreational activities act as a social glue, binding individuals together in shared pursuits. Festivals, for instance, transcend religious and regional boundaries, creating platforms for people to unite in celebration. Sports leagues and tournaments not only promote physical fitness but also provide avenues for camaraderie, teamwork, and friendly competition. These activities offer individuals common ground, a space where relationships form, and social networks expand. Recreational opportunities transcend individual pursuits, extending their reach into the realm of collective engagement. Participation in these activities often requires interaction and collaboration, leading to the cultivation of a sense of belonging within a larger community. Whether through volunteering at cultural events, joining book clubs, or participating in local sports teams, individuals engage in a collective endeavor that nurtures social bonds and mutual support. The availability of a diverse range of recreational activities fosters inclusivity by accommodating a wide spectrum of interests and talents. Individuals of varying ages, backgrounds, and abilities find avenues to express themselves and engage with their community. In this way, recreational activities contribute to breaking down social barriers and creating spaces where diversity is celebrated. The advent of the digital age has also introduced new dimensions to recreational activities. Virtual spaces, social media platforms, and online gaming communities offer avenues for connection that transcend physical boundaries. While fostering virtual connections, these platforms also raise questions about the nature of social engagement in the digital realm and its implications for in-person interactions. --- Equlity and Access Within the intricate tapestry of India's socio-environmental landscape, the equitable distribution of green spaces emerges as a potent lens through which to examine issues of social justice and environmental equity. This segment of the study delves into the multifaceted dynamics surrounding the availability of green spaces, particularly their accessibility and benefits for marginalized communities. The investigation seeks to unveil how these spaces can serve as tools for bridging disparities and fostering environmental equity across diverse contexts within India. Green spaces, often emblematic of natural respite and recreation, take on an added dimension as symbols of social justice. As these spaces offer moments of tranquility and interaction, their accessibility becomes a matter of equitable distribution of resources. Examining the distribution of green spaces and their accessibility within different communities provides insights into the allocation of amenities that contribute to social wellbeing. Green spaces, while providing havens for leisure, exercise, and community engagement, can sometimes perpetuate inequalities if their distribution disproportionately favors privileged communities. Investigating how marginalized communities access and benefit from green spaces is pivotal to understanding broader issues of social justice. The availability of these spaces to all members of society, regardless of economic status, becomes an essential gauge of a society's commitment to inclusivity. The availability of green spaces is intricately linked to environmental inequalities, often reflecting patterns of urban planning and development. Communities with limited access to green spaces may also face exposure to environmental hazards, further exacerbating disparities. By exploring the spatial relationships between green spaces, marginalized neighborhoods, and environmental risks, this inquiry sheds light on the intersections between social justice and environmental concerns. Green spaces are not merely physical entities but spaces imbued with cultural and social significance. Investigating their equitable distribution extends beyond access to encompass the preservation of cultural heritage. These spaces can serve as anchors for cultural expression and community identity, promoting social cohesion and resilience within marginalized communities. The equitable distribution of green spaces intertwines with issues of environmental justice and public health. Disparities in green space accessibility can impact air quality, mental well-being, and physical health outcomes, disproportionately affecting marginalized communities. Exploring these correlations deepens our understanding of how green spaces contribute to a broader framework of social and environmental justice. In the intricate web of India's urban and rural landscapes, the accessibility of green spaces becomes a lens through which to examine the extent of equitable distribution and social inclusivity. This section of the study delves into the multifaceted factors that impact access to green spaces, shedding light on how proximity, transportation, and physical barriers collectively shape individuals' opportunities to connect with nature and communal spaces. The geographic proximity of green spaces to residential areas profoundly affects their accessibility. As urban centers expand, ensuring that green spaces are conveniently located becomes paramount. Analyzing the spatial distribution of green spaces relative to population densities provides insights into the effectiveness of urban planning in promoting equitable access. Proximity is a crucial determinant, influencing whether individuals, particularly those from marginalized communities, can integrate these spaces into their daily lives. The role of transportation infrastructure in mediating access to green spaces cannot be underestimated. Availability of efficient public transport and pedestrian-friendly routes can bridge the gap between neighborhoods and distant parks. Examining transportation options, including walking, cycling, and public transit, offers a nuanced understanding of how communities navigate physical distances to engage with nature. Conversely, inadequate transportation options can create barriers, limiting green space access predominantly to those with private vehicles. Physical barriers, such as highways, water bodies, and infrastructure limitations, can fragment communities and impede access to green spaces. Analyzing the presence of such barriers and their impact on different demographics underscores the intersectionality of accessibility challenges. Marginalized communities often disproportionately bear the brunt of these barriers, reinforcing patterns of exclusion. Evaluating how urban development addresses or perpetuates these barriers reveals a complex interplay between urbanization and social equity. Social and cultural dimensions can either enhance or inhibit green space accessibility. Community perceptions, safety concerns, and cultural norms can influence individuals' decisions to frequent these spaces. A deeper examination of these dynamics reveals the interplay between societal values and accessibility, offering insights into potential strategies to bridge gaps and increase inclusivity. Climate and weather patterns introduce another layer of complexity. Extreme heat or monsoons can influence individuals' willingness to travel to green spaces. Assessing how these seasonal variations impact different communities reveals the need for adaptable strategies that ensure year-round access. --- Policy and Planning Implications By providing a holistic comprehension of the socioeconomic implications associated with urban green spaces, this framework emerges as a valuable tool for urban planners and policymakers. It offers nuanced insights into optimizing the design, allocation, and management of green spaces within urban landscapes. Central to its findings is the call for integrated policies that effectively harness the potential of green spaces to enhance both the well-being of urban inhabitants and the overarching sustainability of cities. This framework underscores the pivotal role of green spaces as more than just aesthetic additions, positioning them as essential components of thriving, resilient, and socially inclusive urban environments. The multifaceted framework, rooted in a comprehensive analysis of the socioeconomic dynamics linked to urban green spaces, holds significant implications for urban development and governance. As urban centers continue to expand, the insights drawn from this framework offer practical guidance for decision-makers. Optimizing Urban Green Space Design: The framework illuminates the intricate interplay between green spaces, community well-being, and economic vitality. It provides urban planners with a roadmap for designing green spaces that cater to diverse needs, from recreational opportunities and cultural expression to health and social interaction. By understanding the nuanced ways in which different communities engage with these spaces, planners can create environments that foster inclusivity and address local demands. Strategic Allocation and Management: With land at a premium in urban settings, the framework's insights into the socioeconomic impacts of green spaces guide informed decisions regarding land allocation. It aids policymakers in striking a balance between commercial development and green infrastructure. Moreover, the framework advocates for strategic management that aligns with the evolving needs of communities. This approach not only enhances green space utility but also maximizes their potential to stimulate local economies. Urban Well-being and Quality of Life: The recognition of green spaces as contributors to urban well-being is pivotal. The framework underscores how access to nature and recreational opportunities can mitigate stress, boost mental health, and enhance overall quality of life. Urban policymakers can leverage these findings to prioritize the creation and preservation of green spaces, safeguarding the health and vitality of city dwellers. Sustainability and Climate Resilience: Embracing the insights from this framework also aligns with sustainable urban development goals. Green spaces play a crucial role in mitigating the urban heat island effect, improving air quality, and contributing to overall climate resilience. By incorporating these considerations into urban planning, policymakers can foster environments that are both socially and environmentally sustainable. In essence, this comprehensive framework serves as a compass for urban planners and policymakers, guiding them toward the creation of cities that are not only economically vibrant but also socially inclusive, environmentally resilient, and conducive to the well-being of all residents. Its holistic perspective underscores the integral nature of green spaces in shaping the cities of tomorrow, inviting collaboration across disciplines to realize a harmonious urban future. Certainly, let's delve further into the implications and potential applications of the framework for urban planners and policymakers: Equitable Urban Development: The framework's emphasis on socioeconomic impacts underscores the importance of equitable urban development. It highlights the potential of green spaces to bridge social disparities by providing accessible spaces for people from all walks of life. Urban planners can utilize this understanding to ensure that green spaces are strategically located in underserved communities, addressing historical inequalities and promoting social cohesion. Community Engagement and Empowerment: One of the framework's underlying principles is community engagement. By involving local residents in the design and management of green spaces, urban planners can empower communities to shape their environments. This not only enhances the sense of ownership but also fosters a stronger bond between residents and their neighborhoods, leading to more sustainable and resilient communities. Economic Opportunities: The framework sheds light on the economic benefits that green spaces can generate. From creating jobs in park maintenance and recreational services to boosting nearby property values, green spaces have a tangible impact on local economies. Urban planners can leverage this data to advocate for investments in green infrastructure, highlighting the potential return on investment and long-term economic growth. Health and Well-being Initiatives: Given the growing concern about urban health challenges, the framework's insights into the positive impact of green spaces on physical and mental health are invaluable. Policymakers can use this information to support health and wellbeing initiatives. By integrating green spaces into health programs and campaigns, cities can proactively address health issues and reduce the burden on healthcare systems. Climate Change Mitigation and Adaptation: Green spaces are essential components of climate change mitigation and adaptation strategies. The framework's acknowledgment of their role in reducing urban heat, improving air quality, and enhancing resilience is crucial. Urban planners can incorporate these findings into broader climate action plans, contributing to the overall sustainability and climate readiness of the city. Tourism and Cultural Preservation: Green spaces often possess cultural and historical significance. The framework's exploration of how green spaces contribute to cultural expression and identity opens avenues for cultural preservation and tourism. Urban planners can collaborate with local communities to design green spaces that honor heritage while providing spaces for cultural events and celebrations. Cross-sector Collaboration: The framework's multidimensional insights necessitate collaboration across sectors. Urban planners, policymakers, environmentalists, public health experts, and community advocates can unite to harness the full potential of green spaces. This collaboration extends beyond government bodies to include NGOs, academic institutions, and private sector entities, fostering innovative solutions and holistic approaches. Long-Term Urban Vision: By integrating the framework's findings into urban development plans, cities can establish a long-term vision that prioritizes the well-being of residents. This vision goes beyond immediate gains, focusing on creating resilient, vibrant, and socially inclusive urban environments that stand the test of time. In summary, the framework's comprehensive exploration of the socioeconomic impacts of urban green spaces extends its significance beyond theoretical insights. It equips urban planners and policymakers with practical tools to craft more resilient, equitable, and sustainable cities. As cities evolve and face increasingly complex challenges, this framework offers a roadmap to navigate the intricate tapestry of urban development while prioritizing the needs and aspirations of the people who call these cities home. The discussion of policy implications and societal shifts is pivotal. The study's insights underscore the need for policies that challenge traditional norms, promote inclusivity, and empower marginalized communities. Furthermore, the narratives suggest that societal shifts are underway, albeit with challenges. This highlights the importance of continued education, awareness campaigns, and grassroots efforts to facilitate change. --- D. CONCLUSION In conclusion, this in-depth analysis of gender realities underscores the intricacies of a multifaceted landscape shaped by cultural norms, evolving identities, educational empowerment, and discrimination. The findings offer a nuanced understanding of the complex web of interactions that define gender dynamics in India. The study's insights call for collaborative efforts from policymakers, civil society, and communities to challenge discriminatory norms, promote inclusivity, and work towards a more equitable and just society for all genders.

This journal article presents a comprehensive exploration of gender dynamics through an indepth analysis of gender realities. By delving into the intricate interplay of cultural norms, evolving identities, educational empowerment, and gender-based discrimination, this study sheds light on the complexities shaping gender experiences. The research employs qualitative methods, including semistructured interviews and thematic analysis, to capture diverse perspectives across India. The findings reveal a nuanced spectrum of gender dynamics, emphasizing the intersectionality of identity, the evolving definitions of masculinity and femininity, and the impact of educational opportunities. The study underscores the challenges posed by gender-based discrimination and violence, while also highlighting the potential for progress through policy interventions and societal shifts. Overall, this research contributes to a deeper understanding of the intricate fabric of gender dynamics, urging for concerted efforts towards fostering gender equality and social justice.

Introduction Current East-to-West intra-European patterns of migration are highly diverse in terms of motivations, temporality, destinations, and outcomes [1][2][3]. This is the result of several decades of massive migrations generated by significant imbalances in terms of economic well-being, labour market opportunities, the functioning and quality of public services in education, healthcare, social protection, etc. Moreover, the recent series of crises have further aggravated such imbalances and disproportionately affected already vulnerable populations in less developed European countries [4]. In this context, the agriculture-migration nexus in Europe developed and embedded a set of mechanisms aimed at facilitating temporary migration for low-wage workers and under relatively poor working and living conditions [5,6]. This framework facilitates the international mobility of low-skilled workers, primarily from Eastern Europe and third countries, to meet the labour demand in highly developed European Union countries where the local population is no longer interested in undertaking demanding jobs, such as those in the agricultural sector. Recently, during the COVID-19 pandemic, it has perhaps become more evident than ever how crucial these migrant flows within the EU are, as their mobility was facilitated by European regulations, even when most countries closed their borders [7][8][9]. Romanian migration developed after the fall of the communist regime in 1989 and became substantial after Romania's accession to the EU , when Romanians gradually acquired European citizenship rights across all EU states [10,11]. However, migration in agriculture had been significant for Romania even before joining the EU, due to multiple bilateral agreements between Romania and other EU countries . These bilateral agreements allowed hundreds of thousands of Romanians to work seasonally in agriculture in EU states [12] and represented important roots for further developments of the flows of international migration. The importance of ethnicity in Romanian migration has led, on one hand, to migrants being oriented towards specific destinations-Germany, preferred by those of German ethnic origin; Hungary, preferred by those of Hungarian ethnic origin; and certain destinations preferred by the Roma minority [11]. On the other hand, it has resulted in a stratification of migrants based on the jobs they performed at their destination and the most disadvantaged minorities, such as Roma people, more often accepting to do challenging jobs, such as agricultural work, at their destination [13][14][15]. The European Commission estimates the European Roma population to be 10-12 million people, with Romania being the European country with the largest number of Roma within the EU [16]. The Roma ethnic minority in Europe is not homogeneous, but there are high levels of exclusion and precariousness in the Roma communities in any country [16,17]. For Roma in Romania, the seasonal work abroad, combined with local casual work and social benefits, plays an important role in providing income and improving housing conditions for disadvantaged people and their families [14,18]. While a significant portion of the knowledge regarding the risks and effects of seasonal migration is derived from research conducted in the destination country on active migrants, there exists a gap concerning longer-term effects on individuals who return to their place of origin, as well as on the families and local origin communities they belong to. Against this backdrop, the article offers an exploration of migration's impact on social structures at the individual, family, community, and societal levels. It explores the intricate mechanisms accompanying migration, providing context-specific insights into affected processes and phenomena. By sharing experiences of Roma communities facing migration challenges, the research highlights their cultural and social dynamics. The next section of literature review introduces a series of useful concepts for understanding seasonal migration in agriculture and the specifics of Romanian Roma migration. Methodological details are presented in a distinct section of this article, followed by a section of qualitative analysis and findings. This article's conclusions discusses the main research results in relation to implications for origin communities. --- Seasonal Migration in Europe: Current Challenges The way it is organized and the recruitment methods in agriculture make seasonal migration a phenomenon in which those in vulnerable categories from origin communities are more frequently encountered [19,20]. This happens because they are the ones most willing to accept demanding manual work at the destination, periods of intensive labour, poor living conditions, and periods of separation from their families. In circumstances where agricultural work is much better paid abroad and their living and working conditions are often precarious both at home and abroad, individuals from socio-economically vulnerable categories show a greater interest in working abroad, even if it means temporarily giving up their social life and the little comfort and well-being they have. Additionally, the social pressure for these individuals can be significantly higher at the family level, as the earnings from working abroad can ensure the short-term fulfilment of basic household needs. The decision to emigrate can thus be interpreted in the terms of the New Economics of Labor Migration [21,22]. This implies that at the household level, certain strategies are adopted to diversify sources of income and to access job opportunities abroad. However, it should be noted that this type of migration is often necessity-driven, given that individuals frequently live in economically challenging circumstances, and seasonal migration can provide them with an additional source of income in a relatively short period of time. The definition of seasonal work in EU legislation refers to a type of employment contract in economic sectors characterized by seasonality and the distinction between intra-European migrant workers compared to thirdcountry nationals [19]. In terms of job market opportunities, it should be noted that migrants face multiple constraints they must accept to work seasonally in agriculture in other countries. Firstly, there is a need for workers only during specific periods , and this entails individuals giving up certain aspects of their personal lives to take advantage of such work opportunities. Secondly, the act of migration under a contractual framework not only establishes a formal commitment between migrants and their employers but also anchors them to specific geographical locales. This linkage, while ensuring a structured work arrangement, often engenders a constrained ability to address and mitigate potential instances of exploitation or abuse [5]. Finally, there is competition between intra-European mobile workers and third-country nationals, serving as a mechanism whereby those seeking intra-European migrants must accept relatively poor working and living conditions [20], or else they risk losing access to these jobs if they are instead offered to individuals from third countries. At the EU level, there are countries with a long tradition of utilizing seasonal workers in agriculture , and after 1990, the map of EU destinations for this type of migration has diversified. An important factor contributing to this diversification was the new phase of agricultural industrialization that Mediterranean countries have entered. The other component of the process is associated with the countries of origin of intra-European seasonal migration in agriculture. In this case, the Central and Eastern European states have become significant sources of migrants, even during the EU's expansion towards the east [19]. The bilateral agreements prior to their entry into the EU provided a clear picture of the scale of such migrant flows. However, a secondary effect of the Central and Eastern European states' EU accession is linked to the disappearance of intra-European seasonal migrant workers from these countries in official public statistics towards other European destinations. Recent studies estimated the number of intra-European seasonal migrants between 650,000 and 850,000, with Romania, Poland and Bulgaria being the countries that have the highest emigration numbers in the EU [23]. Seasonal migrant labour in agriculture, often originating from socio-economically vulnerable groups, entails a series of risks and challenges. Firstly, individuals with lower levels of education struggle to comprehend the information in contracts and legislation. Within the sphere of risks stemming from inadequate knowledge or misconceptions of legislation, scenarios emerge wherein seasonal migrant workers encounter situations where the rightful disbursement of social contributions is circumvented. As a result, these migrants find themselves deprived of the encompassing shield of social protection rights that would ordinarily be bestowed through such financial contributions [20]. Secondly, the demanding nature of the work increases the pressure to violate rights . Thirdly, there is lower attention given to the health and safety of the workers, e.g., ergonomic conditions, injuries, mental health issues caused by separation from families or by the working group at the destination [5,20,23]. The unique challenges inherent in agricultural labour contribute to the heightened vulnerability of individuals already grappling with socio-economic precarity. Furthermore, beyond the immediate risks inherent in temporary seasonal work abroad, a multitude of enduring adverse repercussions are associated with these labour experiences. Termed "hidden costs", these long-term negative effects warrant an in-depth exploration within the context of this scholarly article. During the COVID-19 pandemic, seasonal migrant workers in agriculture were quickly labelled as essential workers for ensuring food security in EU member states [24]. They received increased media attention both at their destinations and places of origin [8]. However, studies indicate that insufficient measures were taken to effectively safeguard their well-being and rights [9]. The lifting of international travel restrictions for these workers had a dual effect. On one hand, it ensured their visibility in the public sphere and drew some attention to the extremely dire living and working conditions they face in destination countries. On the other hand, individuals who lacked the courage or necessary health to undertake seasonal migration risks during the COVID-19 pandemic experienced more pronounced negative effects. This was because many of the social protection schemes implemented in host countries, such as Romania, targeted individuals with suspended professional activities within that country and did not include special measures for those engaged in seasonal work abroad. Furthermore, Rasnača [9] highlighted that certain countries heavily reliant on seasonal migrant labour have altered their legislation. In Germany, this change aims to prolong the stay of seasonal workers, thereby reducing the risk of additional movements that could potentially affect local populations. However, it is worth noting that despite this extended stay, these workers do not receive any supplementary welfare benefits. Both at their origin and destination, these seasonal agricultural workers have become even more vulnerable and have received less assistance compared to other categories of workers [5,9]. The exemption from cross-border movement restrictions was significant only for those seasonal migrants who could benefit from it. However, there were also individuals who, in the context of the pandemic, temporarily interrupted this cycle of seasonal work abroad. --- The Romanian Seasonal Migration: The Perspective of the Origin Country Within the context of Romania, a substantial proportion of seasonal migration comes from regions characterized by heightened agricultural involvement and relatively underdeveloped rural localities [11,25,26]. This dual perspective implies, firstly, that prior agricultural work experience plays a pivotal role in facilitating the adaptation to the labour demands at their destination. Secondly, a compendium of case studies has elucidated the intricate interplay through which migration networks, nurtured within the community, exert a central influence in both the emergence and perpetuation of these migratory pathways [12,13,15]. Moreover, this phenomenon is accentuated by an escalated necessity within these communities to explore work opportunities abroad, particularly due to their constrained local employment options and the deep-seated migratory culture. In a broader sense, this signifies that local establishments in these regions grapple with limited resources to mitigate the adverse repercussions of emigration within the active population. Consequently, a comprehensive examination of these multifaceted dynamics is imperative to forge informed policy measures and ameliorative strategies. The consequences of temporary migration abroad and seasonal migration on migrants, their families, and the communities of origin have started to be studied in the case of Romania. A significant part of this literature is based on community case studies and examines how these localities develop and how returning migrants assume roles as agents of change. In this context, attention was mainly paid to changes in values during migration [27,28], improvements in social status, and the reorganization of existing social stratification [13][14][15]29], as well as the higher propensity in terms of entrepreneurship orientation and propensity towards self-employment [30][31][32]. Many of these effects are seen as relatively beneficial for migrants and the communities, being labelled as forms of modernization [33]. While less attention has been devoted to the negative long-term effects experienced by migrants and the consequent impact on the social-cultural life of communities of origin due to the absence of migrants from the locality for certain periods, certain adverse effects at the family level have been reported. For instance, studies by Botezat and Pfeiffer [34,35] have documented cases where children are left in the care of others or unattended for extended periods of time. These studies have indicated that parents' migration is associated with more severe self-assessed health problems and an increased likelihood of experiencing depression. Moreover, these effects are even more pronounced among children living in rural areas of Romania. Additionally, the lack of care for elderly family members during the migrants' absence has been highlighted by Vianello [36]. When other siblings are living in proximity to the elderly, the migrants provide the necessary economic support, while the remaining family members attend to the daily needs of their elderly parents. At the same time, she found evidence to point out that the lack of care among the elderly left behind exhibits an economic stratification, primarily impacting elderly individuals whose children work as low-wage migrant workers. Last but not least, the specialized institutions for elderly care and support are virtually non-existent in these communities of origin. In both the cases of children and the elderly, scholarly investigations highlight the imperative for migrants to devise strategies to confront the risks and challenges they encounter [34][35][36], given the lack of comprehensive support policies in their communities of origin. In the context of the Romanian state, its orientation has been predominantly geared towards extracting benefits from migration, primarily through economic remittances, and by designing selective programs aimed at encouraging the return of specific Romanian citizens deemed valuable, such as renowned researchers from the diaspora or individuals interested in launching businesses in Romania after residing abroad [37]. Consequently, the most vulnerable individuals, particularly those in dire need of assistance upon their return, find themselves left to independently manage their own necessities or those of their families. --- Roma Population in Romania and Seasonal Migration The Roma population constitutes a significant segment of Romania's general population, both in terms of percentage and in terms of their economic, cultural, and social distinctiveness [16,38]. Although today there is a dispersion of the Roma population throughout the country, a substantial portion of the Roma population still resides in relatively segregated and marginalized communities [14,38]. In historical terms, the Roma population has been recorded in Romania's censuses since 1930. Figure 1 provides an overview of the formal number of individuals registered as being of Roma ethnicity in Romania's statistics. However, sociological studies indicate that mainly due to structural discrimination, there is a consistent underestimation of the Roma population in official statistics [39,40]. According to some estimates, the real number of Roma population from Romania can be between 620,000 and 1.85 million individuals [39] or between 6 percent and 12 percent of the population [41]. While during the Second World War, the Roma population was subjected to physical extermination and deportations, and during the communist era, they underwent a lengthy process of forced assimilation [42], after the establishment of a democratic regime in Romania, the Roma population continued to face structural discrimination, although through less direct mechanisms. In this context of historical evolution, it is understandable why public statistics provide data that do not entirely correspond to the reality in Romania. Using only the data from those who identified themselves Roma would limit both the target groups we could reach as well as the understanding of the lives of those more socially included. The latest therefore prefer "Romanian" as a designation of belonging to and participating in Romanian society. That is why we decided to take into account both the self-identification and the heteroidentification in the description of the localities and the interviewees. Thus, this paper identifies subjects as "self-identified" and "heteroidentified" Roma. This is especially true when it comes to temporary and seasonal migration, rather than a permanent change of residence. Thus, the statistical data available on Roma migration do not allow for a realistic estimation of the current extent of this phenomenon but only show that the Roma population is present in migration [43]. In the most recent census conducted in 2021, only 10,797 individuals of Roma ethnicity were registered in Romania as having had previous residence abroad. Certainly, the actual number of individuals who lived abroad and have returned to Romania is much higher. In 2018 a World Bank's report [41] provides comprehensive statistics about the socioeconomic disparities faced by the Roma population in Romania. One of the most evident issues is that 70 percent of Roma were at risk of poverty, and this is a substantial gap to the national average . Moreover, 68 percent of Roma lived in segregated neighborhoods, and employment data revealed that only 46 percent were employed, compared to the national rate of 66 percent. The same report emphasizes that the education gap is equally concerning; while 86 percent of non-Roma children participate in early childhood education, only 38 percent of Roma children were enrolled in such programs. Only 77 percent of Roma children who should have been attending school were enrolled, with 77 percent of Roma aged 18-24 dropping out early. Alarmingly, 15 percent of 7-to-14-yearold Roma were not attending any educational program. Equally troubling is the fact that 63 percent of Roma in the 16-24 age group were not in employment, education, or training. A survey conducted in 2011 indicated that a significant 13 percent of Roma were contemplating moving to another country, reflecting a greater aspiration for migration compared to the non-Roma population in nearby areas, which stood at 9 percent [44]. First and foremost, there exists a long history of discrimination against the Roma community, leading to increased socio-economic vulnerability within this group [45][46][47][48]. During the communist era, multiple assimilation policies were implemented as part of the broader process of homogenizing and controlling the country's population. After the collapse of the communist regime and during the transition to a capitalist economy, the Roma population was largely left out of development policies for a considerable period. Moreover, during the communist era, the Roma population in rural areas worked on collectivized farms alongside other rural residents. After the dissolution of these collective farms and the transfer of agricultural lands to private ownership through land restitution and privatization, the Roma population was among those most affected [49]. This was because most of them did not have agricultural lands to be restituted to them, and the jobs that were available during the communist period disappeared. At the same time, following the opening of Romania's borders, the Roma population was among the first to explore the opportunities presented by international migration [11]. Consequently, the post-communist decades were a period of increased mobility for the Roma population. It was only after Romania's accession to the EU that some national policies began to be implemented to reduce discrimination and enhance the integration of the Roma population, but their effects were rather modest if we consider the amplitude of these structural challenges [46][47][48]50]. In 2018 a World Bank's report [41] provides comprehensive statistics about the socioeconomic disparities faced by the Roma population in Romania. One of the most evident issues is that 70 percent of Roma were at risk of poverty, and this is a substantial gap to the national average . Moreover, 68 percent of Roma lived in segregated neighborhoods, and employment data revealed that only 46 percent were employed, compared to the national rate of 66 percent. The same report emphasizes that the education gap is equally concerning; while 86 percent of non-Roma children participate in early childhood education, only 38 percent of Roma children were enrolled in such programs. Only 77 percent of Roma children who should have been attending school were enrolled, with 77 percent of Roma aged 18-24 dropping out early. Alarmingly, 15 percent of 7-to-14-year-old Roma were not attending any educational program. Equally troubling is the fact that 63 percent of Roma in the 16-24 age group were not in employment, education, or training. A survey conducted in 2011 indicated that a significant 13 percent of Roma were contemplating moving to another country, reflecting a greater aspiration for migration compared to the non-Roma population in nearby areas, which stood at 9 percent [44]. First and foremost, there exists a long history of discrimination against the Roma community, leading to increased socio-economic vulnerability within this group [45][46][47][48]. During the communist era, multiple assimilation policies were implemented as part of the broader process of homogenizing and controlling the country's population. After the collapse of the communist regime and during the transition to a capitalist economy, the Roma population was largely left out of development policies for a considerable period. Moreover, during the communist era, the Roma population in rural areas worked on collectivized farms alongside other rural residents. After the dissolution of these collective farms and the transfer of agricultural lands to private ownership through land restitution and privatization, the Roma population was among those most affected [49]. This was because most of them did not have agricultural lands to be restituted to them, and the jobs that were available during the communist period disappeared. At the same time, following the opening of Romania's borders, the Roma population was among the first to explore the opportunities presented by international migration [11]. Consequently, the post-communist decades were a period of increased mobility for the Roma population. It was only after Romania's accession to the EU that some national policies began to be implemented to reduce discrimination and enhance the integration of the Roma population, but their effects were rather modest if we consider the amplitude of these structural challenges [46][47][48]50]. The primary socio-economic challenges for the Roma population in Romania are closely linked to low levels of education, low employment rate in the formal economy and lack of satisfactory job opportunities, as well as difficult access to healthcare infrastructure. Behind these issues lies a complex set of structural barriers that have hindered the Roma population's access to education and the acquisition of qualifications needed for access to satisfactory employment [51]. In this context, seasonal migration, due to its lower economic costs, has been one of the significant migration options within Roma communities [14,15]. Furthermore, the fact that recruitment for seasonal agricultural work often relies on social networks has facilitated its rapid spread within Roma communities. During the COVID-19 pandemic, the situation worsened significantly for vulnerable populations compared to the general population. In Romania, the Roma population found themselves in such a situation, and life in Roma communities became more challenging than before [18,50]. Among the dimensions of life that were most severely affected were health, education, and social protection. Living conditions in Roma communities and overcrowded housing created favorable conditions for the virus's spread and exacerbated pre-existing health issues [50]. The shift from in-person to online education posed greater difficulties in Roma communities because many students lacked the necessary digital devices and skills, and parental support was less prevalent [52]. Last but not least, the fact that the Roma population has higher rates of informal labour and seasonal migration for work meant they were often overlooked by government programs aimed at providing social protection to those whose employment was suspended during the COVID-19 pandemic [18]. To sum up, the context in which the seasonal agricultural migration of the Roma population in Romania can be understood requires considering several factors. First, discrimination and structural barriers have caused lower levels of education and qualifications and have limited the Roma population's access to the Romanian labour market. Second, migration within Roma communities emerged immediately after the opening of borders and has remained a significant option due to the persistent poverty at their place of origin. Also, social networks within these communities facilitate the rapid spread of information about opportunities abroad. Additionally, Roma communities were marginalized and excluded from national, regional, and local development policies and programs because this population segment was constantly underrepresented in political power structures [46,53]. These factors have combined to create a situation where seasonal agricultural migration has become a key strategy for many Roma individuals and families, offering a means to escape economic hardship and discrimination within Romania. --- Materials and Methods This paper is underpinned by a qualitative methodology and fieldwork conducted within four Roma communities in Romania, situated within the overarching framework of the research project entitled "The role of religion and religious actors in Roma social inclusion: towards a participatory approach" . While the project primarily aimed to comprehend the multifaceted challenges that Roma communities currently encounter across various dimensions of their lives, including economic, social, and spiritual aspects, the overarching objective of this study is to uncover the hidden effects stemming from seasonal agricultural migration within Roma communities in Romania. This research goal emerged after a preliminary analysis of the gathered data, as we recognized the pivotal role of migration within the communities under study as well as their multi-dimensional consequences. Although the study does not disregard positive outcomes or neutral transformations, these aspects have been more comprehensively addressed in existing literature. In pursuit of our research objective, the investigation is guided by the subsequent research questions: What are the principal negative consequences of migration within Roma communities? How do the migrants themselves, the families left behind by migrants, and relevant community-level entities discuss these challenges? The research design incorporated in-depth interviews with members of the Roma community and semi-structured interviews with key stakeholders, including representatives from public authorities, social workers, religious leaders, and school educators, alongside fieldwork notes compiled by the researchers engaged in data collection. Access to the communities and the selection of respondents were facilitated by local co-researchers, who were trained as part of the project. These local co-researchers acted as intermediaries between non-local researchers and the community, and on some occasions, they were present during interviews to ensure the psychological comfort of less-educated Roma participants. Data collection was between March and November of 2022, yielding a comprehensive sample of 123 interviews. The structure of the sample is detailed in Table 1, elucidating the relationship between the county, the locality, the total count of interviews, the number of interviews conducted with Roma individuals, and the number of interviews conducted with key stakeholders. VL2. A rural municipality with about 5000 residents, including 1800 Roma. A part of the Roma population is composed of descendants of slaves from the monasteries. The Roma community can be found all over the commune, but there is also a segregated community. 24 17 7 Source: Authors' elaboration based on the data collected in PARI Project. The selection of the two counties and of the four communities where the data were collected was made considering several aspects. Firstly, the aim was to cover, to the greatest extent possible, the diversity of historical, social, and economic contexts in Romania. Although the two neighboring counties belong to different historical regions and are inhabited by distinct groups of Roma people with historical, cultural, and social differences, the study did not intend to be nationally representative. We attempted to avoid being anchored to overly specific local contexts in this qualitative study and to move beyond the local case studies, which are most common in researching Roma communities in Romania. Secondly, there was openness within these Roma communities towards the research themes, allowing for the recruitment of co-researchers who could facilitate community understanding and participate in data collection. Within these communities, efforts were made to engage with individuals representing diverse socio-demographic backgrounds . Key stakeholders were selected based on their frequent interactions with Roma individuals, ensuring they could provide valid and complementary insights into life within these communities. The number of interviews in each community was planned from the outset, taking into account the research resources available and ensuring a sufficiently large number of interviews to facilitate potential comparisons across specific dimensions of analysis. Source: Authors' elaboration based on the data collected in PARI Project. The analysis was performed on verbatim transcriptions of audio-recorded interviews, augmented by the incorporation of research notes compiled by the researchers. Notably, the interpretation process considered both these transcriptions and the researchers' field notes. The interviews, on average, spanned a duration of approximately 50 min each, contributing to a wide-ranging exploration of the topics. The thematic data analysis was performed by using the NVivo software . The research design and the whole data collection procedure received ethical endorsement from the Ethics Committee for Social Sciences at Lucian Blaga University of Sibiu. --- Results The data analysis is guided by the research objectives of this article and was executed through the coding of transcribed interviews. In this context, the codes emerged from a thematic analysis [54] of the interviews and enabled a deeper comprehension of how the effects of migration manifest at the individual, familial, and community levels within the migrants' local origins. To depict the extent of the phenomenon, we can resort to the words of a local Roma resident who states: '. . . [during some periods of the year] the village remains empty. . . Excuse my frankness, one could even walk around naked without anyone noticing!' . However, one of the key actors adds 'they don't leave for a period of 1 year, 2, 3, 5. . . we believe that 80% were those who engage in seasonal migration'. --- Individual Level In the context of economically motivated migration, the individual often assumes the decision to migrate and simultaneously foresees, to some extent, the outcomes associated with the migration experience. Through the lens of a cost-benefit analysis, it is expected that the individual will migrate when the benefits outweigh the estimated costs. However, as we will observe, certain negative effects exist, representing the less conspicuous facets of migration that migrants frequently overlook for financially gain from overseas migration. In Romania and other societies, there is documented evidence of a tendency for individuals of Roma ethnicity to drop out of school more frequently or exhibit higher rates of absenteeism. This can be partially explained by the cultural specifics of Roma communities, which include significant gender differences regarding the education of boys and girls. However, migration adds a new element of pressure on the school involvement of Roma children. Firstly, the prolonged absence of parents can facilitate absenteeism or dropping out for children. Secondly, the pursuit of academic success and building a professional career through education becomes less valued if the economic model of success in the community is offered by those who work seasonally abroad and return with sums of money that others cannot earn within the same timeframe in the home country. Well, many people are engaged in migration, because they are not satisfied with the wages here in Romania. What can they do with 15 million [about 300 EUR], and a 2-3 million [about 50-75 EUR] bonus in a month? Over there, in a month, they bring in three times what their salary is here-it is quite substantial. Going abroad suits them better because they earn much better there, even with the same salary they would get in Romania. . . They work for two or three months there, the money they make lasts for about a month here, and then it's the same cycle again. [Interviewer] And do you happen to know, did any of them drop out after elementary school [end of fourth grade] before middle school? Some of them dropped out, yes! . . .but because of the parents. . . the parents went abroad and the grandparents, well. . . they didn't send them to school anymore. . . so migrating abroad has a significant impact on children. The lack of interest in jobs in one's country of origin carries hidden costs for migrants. In the literature review, we presented studies that documented a long tradition of discrimination against Roma on the Romanian labour market. However, the emergence of new factories in peri-urban areas in Romania and the scarcity of labour force created new employment opportunities [55]. These businesses provide transportation for workers through minibuses, facilitating their commute from further rural areas, and they are also interested in employing low-skilled Roma individuals and provide them with qualifications through different training programs. Certainly, the wage levels are lower compared to those abroad, but local employment comes with the attendant benefits arising from contributions to the social protection system-unemployment benefits if an individual remains jobless, child-rearing allowances for the first two years following a child's birth, pensions, and so forth. Earnings from working abroad are quickly allocated to the daily household needs, thus preventing savings for the post-retirement period. In this scenario, the pension system should cater to the needs of those who amass sufficient work experience. By engaging in foreign agricultural labour, the obligation to contribute to the pension system is avoided, leaving long-term vulnerabilities for individuals practicing this form of migration. It's very difficult. . . To tell you the truth, I go to the store many times. Do you think I came back without any meat? Because it's incredibly expensive. Well, when I think about having to pay for electricity, TV cable, and water. . . And not just now, for instance, if the children weren't working [abroad], what would I use to pay? I have no income. I am fortunate that they go away and send money home to cover everything. As indicated by studies referenced in the literature review section, seasonal migrant workers in agriculture endure challenging working conditions abroad. They often work beyond regular hours and face higher risks of workplace accidents than others due to laboring under conditions of fatigue and occasionally operating machinery they are not adequately familiar with. Additionally, they are compelled to work in unfavorable weather conditions and adopt physically demanding postures. Many of these challenges are anticipated by those engaged in seasonal agricultural labour and are somewhat accepted at the time of departure. However, the negative health effects can persist over the long term, as working under such conditions generates enduring difficulties. In the case of the Roma minority, this is exacerbated by the fact that many of them do not seek medical treatment or preventive care; instead, they often only resort to emergency rooms in critical situations [56]. By correlating these factors, it becomes apparent that many of the health conditions that seasonal Roma agricultural migrants develop during their work experiences remain untreated and worsen over time. This strongly impacts their quality of life and healthy life expectancy. . . . two years ago, I was in Denmark, and I tell you honestly, with my hand on my heart, that we used to go and search for carrots, peppers, vegetables-we would take them from the trash can. And I used to wash them because it was very expensive; with the money we earned there, we couldn't afford it, as I also had to send money to my children and grandchildren in the country. And I genuinely tell you that some took expired meat and salami, even if it was two-or three-days past expiration-they would take the meat. But I didn't take meat. I couldn't do that. There were about 400 Romanians all together. . . Poor us! There were no proper conditions, nothing. I stayed and endured because living here in Romania is very difficult. There are many who went abroad and came back dead. Without questioning that seasonal Roma migrants earn more abroad than in Romania for the periods they work, individual-level analysis reveals that there are also relatively hidden costs associated with this migration. Thus, we can observe patterns of negative thinking about job opportunities at home or possibilities for further education. Attention can also be drawn to the impact on health and the lack of concern regarding these consequences upon return. --- Family Level In the existing literature, certain positive effects have been documented , as well as some negative effects . Beyond these, we propose the examination of less visible aspects such as tensions within families due to the excessive burden placed on women, the transformation of marital supervision, and the overall vulnerability of the family in the face of crises that jeopardize the cyclical nature of seasonal migration. The separation of migrants from other members of the family, whether nuclear or extended, has profound implications for family organization and for each member of the family. If infidelity or presumed infidelity occurs between the couple, it can lead to instability, conflict, divorce, abandonment. At the family level, we can cluster the negative effects of migration on migrant children, spouses/partners left at home, and non-migrant elderly parents/grandparents. In terms of the effects on migrant children, migrant children are the most affected, whether accompanying their parents or staying at home. There are obstacles to school reintegration for Roma children who accompanied their parents abroad for seasonal work. Children who accompany parents on seasonal migration sometimes remain out of school and many are forced to drop out. They did not let the child attend education because they were somewhere . . . in the sheepfold and they took the children with them and because of that they interrupted . . . the educational cycle, because of that. . .pity, pity In Roma communities, a traditional family model still predominates. This entails welldefined gender roles: the man is tasked with providing the necessary income for subsistence, while the woman is responsible for raising children and managing the household. There exists an unequal power dynamic, with the man being the primary decision-maker for the family. Furthermore, families are relatively large and often involve multiple generations living together. For a significant duration, the Roma population has engaged in forms of extended family group migration: several families accompanied by children and, at times, the elderly. In this context, seasonal migration for agricultural work disrupts family life as it is typically practiced by one member of the household . Within our sample, one of the issues of this nature pertains to the transfer of supervision of women from their partner to his family remaining in the home country. Even if the woman accepts this type of arrangement, the situation generates significant discomfort and represents an additional pressure on the Roma woman who is already overloaded with tasks and responsibilities. Furthermore, the absence of the husband from the household leads to a state of social isolation for the Roma woman because it is not customary for her to participate in social events without a husband, and involvement under the supervision of in-laws or extended family can be avoided when relationships are not at their best. . . . If he [the husband] is away and I want to go somewhere with my father-in-law, I can. But if there is a wedding, a christening, or events, and he is not at home, no. It is not considered very appropriate for a woman to walk alone. . . It's somewhat frowned upon for a woman to go without her man. In the case of a young man. . . The time for marriage came, and he took a young girl, but not from his village, from another village, and they didn't get along. . . every time he went abroad, she would run to her parents, and he was unhappy about this. He noticed it once, twice, and tried to have a family meeting. . . The point is, one day, she went to her parents and didn't come back. When he returned from abroad, he tried to go get her back. The family didn't agree anymore. And so, to put it that way, a dispute began. As both the literature review and the fieldwork indicate, migration for work in agriculture is practiced for economic reasons in these Roma communities, and the money earned from migration are essential for covering the current household expenses. In this context, even the temporary abandonment of seasonal agricultural migration has generated complex and dramatic situations within families who depended on these incomes. Not only have those who could not leave become more vulnerable, but their entire families as well. During the pandemic time it was very difficult for them. Whereas before, they could work as daily laborers in the summer or anytime during the year, during the pandemic, due to restrictions, they couldn't even work as daily laborers anymore, because, you know, it was like that time when the police were checking everywhere, which. . . And then, almost all of them were close to starving. Abroad, they couldn't go anymore because the borders were closed. They couldn't work as daily laborers anymore either, due to the situation with the restrictions that were in place. So, it was an extremely tough period for them. There were times back then when they almost had nothing to put on the table, they couldn't even come to beg in Sibiu because they couldn't. . . the police would catch them. Those who are left are old, they are old, and they are lonely, they must be visited, they have to . . . they are helpless, some are barely moving around the house. . . --- Community Level The impact of migration on communities of origin around the world has been identified at several levels and dimensions of social life. Seasonal migration affects local and national economies and can transform the political landscape [6,57]. The labour market at origin is affected by seasonal migration [58]. There is a negative effect of seasonal migration on the labour supply of non-migrants. To put it in Roma individuals' words: the oldest, the sick, those who still have a helper remain . . . Now no one works anymore, the land is not worked anymore either-no one has dinner anymore, all the young people have left. Old people can't do it anymore. At the community level, our data reveal at least two hidden effects generated by this type of migration within the studied Roma communities. The analysis focuses on effects related to social stratification within these communities and on unanticipated consequences that arise in the implementation of development programs by public authorities. Even though other studies have documented changes in status and transformations regarding social stratification at the community level [14,15], evidence indicates that these changes give rise to a range of new social tensions within the respective Roma communities. Such attitudes are evident in the negative judgments expressed about those who engage in migration-portrayed as driven solely by monetary greed. Additionally, migration is responsible for generating economic inequalities in communities that were previously relatively homogenous. Individuals who accumulate more than those who do not participate in migration are perceived as more prosperous and are subject to community-level judgments. I wouldn't go anywhere else; I don't like going abroad. I grew up here, and I've stayed here. I prefer being at home. . . Here, you know everyone personally, and this is home. I believe that those who work hard can earn money, and they don't need to go abroad for that. However, perhaps people have different ideas, and they chase after money, losing touch with life-they're just chasing money. You see, it's not long before this community will be divided into two classes-a wealthier one when people return with income from abroad, and a poorer one. Do you understand what I'm saying? Envy naturally emerges. . . In a somewhat different vein, hidden effects of this type of migration can be identified concerning the attitude of public authorities and the programs they implement within Roma communities. Given limited community resources, public authorities appear relatively content with migration seemingly alleviating extreme poverty and relieving them from the social pressure that otherwise would have demanded solutions to various issues. Evidence indicates a preference for relatively passive roles, where individuals and families are left to seek solutions for poverty on their own, and integrated public programs are exceedingly rare. The community has changed a lot in the last 15 years. . . Here are people who work very hard. . . but I believe they were disadvantaged because I think even the municipality did not invest in them. They still have unpaved roads. Many have worked abroad and have properly set up their homes. Qualitative data analysis reveals multiple facets of seasonal migration within the Roma communities in Romania. Beyond the generally acknowledged positive economic effects associated with migration to countries with better-paying work opportunities, it becomes evident that individuals are discussing seasonal migration in agriculture as having some detrimental medium-and long-term effects on individuals, families, and communities. These constitute hidden costs of migration, and often, individuals or families engaged in migration do not consciously assume them. In order to provide a quantitative overview of the results, we synthesized the coding process outcomes in Table 3 --- Discussion The article aims to make a significant contribution to the critical discourse surrounding seasonal migration in agriculture and its ramifications at the point of origin. Specifically, the focus is directed towards Roma communities in Romania, which are deeply entrenched in this contemporary phenomenon. By drawing upon the existing body of literature and leveraging recent qualitative fieldwork, our primary objective was to discern the less conspicuous impacts of this form of migration. Seasonal migration in agriculture represents a highly distinctive type of international mobility due to its inherent temporality, cyclic nature, as well as the associated labour and residential conditions. The periods of intensive work entail elevated risks for individuals and give rise to a spectrum of enduring consequences. The demanding nature of such labour predominantly attracts individuals from low-skilled and economically vulnerable categories of people. While research within the EU context has predominantly centred on labour dynamics and living conditions at the destinations, relatively limited attention has been directed towards the longer-term effects on individual migrants, families left behind, and the local communities of origin. The originality of our paper lies in the exploration of these hidden effects. Moreover, the article complements the recent research conducted in destination countries [5] and provides an origin-grounded perspective on the transfer of some production costs from producers to seasonal laborers. By delving into these consequences at the individual, familial and community level, our study poses a challenge to existing policies and the optimistic comprehension of intra-European seasonal mobility flows for work in agriculture. The methodological design of this study allowed us to employ a comprehensive perspective on the effects of seasonal migration at origin. The substantial number of indepth interviews conducted within four Roma communities, along with the semi-structured interviews involving key actors from the community, unveiled real issues stemming from seasonal migration. To enrich the existing literature in the field, the analysis was structured around the three dimensions and focused on hidden costs of migration. On one hand, the article gives voice to Roma migrants and their families, while on the other hand, it provides an insight into how key actors within the community describe the effects of seasonal migration on the community's life. At an individual level, seasonal migration enables individuals to earn significantly more abroad during the seasonal work than they would have earned at home [14,59]. However, the costs for these earnings are higher, and some of these costs are paid long after the migration experience has ended. Firstly, physical health is affected by the physical strain during these periods, and health issues persist for the individual to be addressed upon their return. In terms of education, young people who opt for a path of seasonal migration and forego educational prospects lose the opportunity for professionalization and access to better job opportunities in the future. Finally, we have shown that seasonal work abroad deprives individuals of access to certain social protection systems for situations when they are unable to work for a period. At the family level, empirical evidence aligns with the consulted literature, highlighting that seasonal migrants delegate certain caregiving responsibilities for children and the elderly during their periods abroad. Regarding its impact on families, we have provided insights into the effects on family life and childcare when parents temporarily migrate abroad, shedding light on a distinct population group in addition to the findings revealed by Botezat and Pfeiffer [34,35]. Furthermore, while the relationship between spouses in the context of temporary migration and return has been discussed in the case of the general population of Romanians by Vlase [27,60], our study offers insights into how the migration experiences described in the article restructure certain aspects within Roma families. Our research introduces novel elements concerning the transformation of partner relationships and social tensions arising from the extended family's supervisory role over the spouse remaining in the home country. Furthermore, recent evidence during the COVID-19 pandemic has allowed us to observe that any disruption in the cyclical nature of seasonal migration generates detrimental effects for the entire family, as they have become financially dependent on migrant earnings and have forsaken local commitments. Roma communities also suffer due to seasonal migration. Our study contributes to a better understanding of the effects of seasonal migration on communities and adds new knowledge beyond what has been previously documented [13,15,29]. Also, it develops the knowledge about the migration's consequences in central region of Romania [30] and in Romania as country of origin and return [11]. Beyond the evident depopulation during certain seasons and the absence of young individuals as a source of support for household and communal activities, there are social tensions arising from envy and social re-stratification. Those who do not have access to migration for various reasons tend to negatively view those who do practice it, highlighting that they leave their children or the elderly in the care of others. Another significant effect that we have identified pertains to how local authorities tend to overlook the issues faced by Roma communities, as seasonal migration ensures their subsistence and diminishes their acute social problem status. This complements the prior research focused on the political under-representation of Roma in local and national administrations [46,47,53]. The lack of programs and investments in these communities will lead to major long-term issues and perpetuate a cycle of underdevelopment. The topic addressed in the article lies at the intersection of European Union policy instruments. On one hand, it pertains to policies aiming to reduce poverty and enhance the social integration of the Roma population in Romania. This has been translated into a national strategy already implemented in Romania, funded both through national resources and European framework programs. On the other hand, the focus of this study falls within the realm of European policies directed towards the better management of intra-European seasonal migration flows and how mobile European citizens working in agriculture can enjoy improved social protection both abroad and in their home countries. In fact, our study bridges these two significant domains of European policies and highlights the need for integrated policies to alleviate the vulnerability of populations living in precarious conditions, resorting to mobility as a last alternative [43]. --- Limits of the Study The limitations of this study are associated with qualitative research methods and the non-extrapolation of the findings. Certainly, the seasonal migration in agriculture from the perspective of its origin should consider the contexts from which individuals depart and to which they return and important differences can occur between communities of origin. Furthermore, the concentration of interviews within Roma communities hindered the comparison of identified effects with realities in Romanian non-Roma communities, which are in general more developed in terms of housing, labour market, and the quality of local institutions. --- Data Availability Statement: Raw data are unavailable due to privacy or ethical restrictions. --- Informed Consent Statement: Informed consent was obtained from all subjects involved in the study. ---

The article is focused on researching the hidden effects of seasonal migration in agriculture on Roma communities in Romania. The theoretical framework considers the specific nature of seasonal migration in agriculture and includes elements relevant to understanding the seasonal migration patterns of the Roma population from Romania. The research is based on a qualitative methodological design and over 120 interviews in four communities with Roma individuals and key actors at the community level (e.g., local authorities, teachers, priests, and social workers). The interviews are thematically analyzed, and the hidden costs of seasonal migration are discussed at three levels of analysis: individual, familial, and community. First and foremost, the analysis emphasizes that migration is the most significant factor of social change in the studied Roma communities, and its effects are multifaceted. The analysis reveals significant negative costs of migration in terms of health, education, employability, family, and community life. In the medium and long term, these effects decrease the positive aspects linked to the material gains from migration, making these Roma communities more vulnerable and dependent.

Introduction This article examines the return migration to the Kurdistan Region of Iraq in the 2000s. It sheds light to the returnees' motivations to return to Kurdistan in the post-Saddam era as well as to their pre-and post-return experiences and how those affect plans to re-return. Since the 1980s, the Iraqi Kurdish migration to Europe and North America has mainly been conflict-generated due to experienced ethnic persecution and lack of human security in the context of war and political instability. After having formed vibrant diaspora communities, thousands of Kurds have returned temporarily or permanently to the region since the invasion of Iraq in 2003 by American-led forces and since the establishment of a semi-state structure in Kurdistan . 1 The KRI has experienced a significant economic boom in the 2010s and the Kurdish Regional Government has become a prominent actor in the Middle East after 2003, when the Ba'athist regime's reign terminated and the Kurdish political actors replaced its political institutions . This has led to numerous diaspora members, who were forced to flee the region due to a series of genocidal campaigns , political instability and even war, to return to the region in the post-Saddam era . However, the newly erupted war between the KRG and the so-called Islamic State has presented new dynamics for migration to and from the region. Thousands of young Kurds have left the region due to the on-going conflict, which shows that while diasporans are returning many locals also dream of leaving Kurdistan . The eventuality of an independent Kurdish state since the declaration of the de facto Kurdish state in 1991 seems to never have been as topical as it is now with the failing state of Iraq . The KRG held a referendum for independence in September 2017, evoking reactions from its neighbors Turkey, Iran and Syria as well as from the central Iraqi government. This will surely affect KRG's political and economic situation in the long run, as independence claims might destabilize even further the political dynamics in the region . This also means that the voluntary return of diasporans, who have spent years outside Kurdistan might not be sustainable and permanent in the long run. In this paper, we ask: What has motivated the return migration of Iraqi Kurdish diasporans to the KRI in the post-Saddam period? How do their pre-return experiences shape decisionmaking processes concerning return? And, how do both pre-and post-return experiences play into plans of a possible re-return? This study on Iraqi Kurdish return migration provides a compelling case to examine diaspora members' return to a post-conflict context that is highly volatile. It allows shedding light to the dynamics of return migration by examining what role pre-return experiences play in decisions of return, but also how they together with post-return experiences affect plans of eventual re-return. The article is based on fieldwork conducted in 2016. The material consists of qualitative, semi-structured interviews conducted with voluntary and non-assisted returnees to the KRI from ten different host countries in Europe and North America. It provides insights to diasporans' motivations to return in a context of active nation-state building processes in the 'homeland', and on how their experiences both before and after return affect plans to stay or to re-return. The findings show that plans to opt for re-return to host society were largely shaped by the mismatch between the expectations associated with a diasporic homecoming and the realities on the ground, with the latter being contrasted to positive experiences in the host countries. The following sections include a literature review on relevant empirical and theoretical studies on return migration, a section on methodology and the data collection procedures and the analysis sections that present the central findings. The article ends with a discussion on the policy relevance of the findings. --- Return as Diasporic Homecoming Research on return migration has exponentially increased during the last decade or so, although certain sub-themes have drawn more attention than others, including the decision to return, post-return reintegration and reverse cultural shock . One of the major themes of interest in return migration literature concerns the motivations for return migration, and in which cases the intentions to return concretize into an actual return to homeland . Scholars have focused on factors such as age and generation , economic opportunities and investments , family ties or other personal motivations and transnational ties and engagements to better understand the link between the possibilities and intentions of return and the actual return to homeland. More recently, it has been posited that the impact of host society integration , in other words the social and economic conditions in the host country, including discrimination, failed labour market integration and feelings of non-belonging, might also motivate return migration. Reasons to leave the 'homeland' can also play into motivations to return. Whereas the empirical research literature on return rarely distinguishes between that by labour migrants and those of forced migration movements, we can say that the return dynamics are not similar to these two types of migration patterns. Although it is difficult to categorize return motivations to a post-conflict region in a clear-cut manner as different motivations often intertwine, Tsuda argues that 'despite its fundamentally instrumental economic basis, diasporic return continues to be more ethnically driven and emotionally charged than other types of labour migration.' For instance, several case studies show that identity-driven motivations and feelings of belonging to the 'homeland' play a role in return decisions in the first but also in the second generation. On the other hand, in the context of active nation-building, identity-driven or nationalist reasons to return to ancestral 'homeland' can also play a major role in return decisions and desires to contribute to local development processes . The motivations of voluntary return by forcibly displaced diasporans, as is the case with the Iraqi Kurdish diaspora, to a post-conflict society that is in the stage of active nation-building, remains largely understudied. How can such 'ethnically driven and emotionally charged' return be better understood, without essentialising return as a mere reflection of lingering ethnic loyalties and yearnings? Markowitz and Stefanson refer to 'homecomings', drawing from Brah's notion of the 'homing desire'. They suggest that return is not merely a nostalgic belonging to a homeland, to the past condition or a defensive response to the stigmatization in the host society, but that the return can become a project that opens doors to the future. However, the return is not always frictionless and the returnees can find themselves struggling with reintegration if realities on the ground drastically differ from their expectations. Besides host country experiences and how those are reflected in return decisions, more and more is known about returnees' individual experiences and the mismatch between their expectations and the realities they face in the homeland . As mentioned earlier, prior research has established that decisions to return can be shaped by expectations of what awaits in the 'homeland' as well as by diasporans' experiences of the host country. We suggest that pre-return experiences in the host country together with post-return experiences in 'homeland' affect decisions to stay or eventually to re-return. This means that not only decisions concerning return but also re-return to host societies are shaped both by the realities in the homeland and prior experiences in the host society. Yet, relatively little is known of how host society experiences together with post-return experiences shape decisions to stay or to re-return. What can then be considered as 'return'? As King and Christou observe, there is a more 'variegated and nuanced exploration of the ontology of return, stretching its meaning across time, space and generations, and where the 'place' of return and the type of movement can have various expressions -real, virtual, imagined, desired, forced or denied'. We approach 'return' similarly to Long and Oxfeld , who understand it as ranging from short visits to more permanent repatriation, including temporary visits and preparations for return. This is different from 'return migration' that is accompanied with the intention of staying permanently, whereas 'return' can also be provisional and include short-time visits. Drawing from Long and Oxfeld's understanding of 'return', from Brah's understanding of diasporic, and Markowitz's and Stefanson's understanding of 'homecoming', we approach the return of Iraqi Kurds to the KRI as diasporic homecoming. We understand diasporic homecomings as either a provisional or more permanent return that is at least to some extent motivated by feelings of returning 'home' and willingness to contribute towards it, but that is also informed by both pre-migration and pre-return experiences in the host society, and future-orientated with the possible idea of re-return -and so forth. Theoretically, return migration has been approached within the paradigms of transnationalism, diaspora and mobilities 2 . This paper draws from the transnational frame in the sense that it examines how decisions and motivations for return become formulated in relation to pre-and post-return experiences in both the national and transnational context. International migration has become more and more seen characterized by multi-sited transnational networks and mobilities, although scholars have acknowledged that the context in which the departure as well as the return takes place is highly important . The transnational frame provides an analytical lens to recognize how returnees make decisions in the transnational space, but also how their national human and social capital shape their decisions to return, and plans to re-return. --- Methodology As return migration is dynamic and complex by nature, qualitative approaches have become a preferred method in migration studies . The primary data source for this paper consists of 26 semi-structured interviews conducted in three main provinces in the KRI, namely Erbil, Sulaymaniyah and Duhok in early 2016. Furthermore, in this study we have solely focused on voluntary, non-assisted return, where the individuals have made the decision to return to the ancestral homeland without the existence of a threat of deportation or reasons for forced return. The semi-structured interview guide was prepared by the authors and interviews were conducted, translated from Kurdish to English, as well as transcribed and anonymised by a research assistant3 . This data collection method allowed the interviewees to narrate their own individual experiences . The interview data was then coded by the authors, divided in empirical categories and then re-grouped to themes each of which is dedicated a separate analysis section. [Table 1 here] Snowball sampling method was used in order to reach the interviewees. The authors and the research assistant used their previous contacts and pursued several leads so that the snowball sampling would not rely only on few contacts. This data collection strategy was chosen for a variety of reasons. Firstly, there is no official data on voluntary returns to the KRI and returnees are not easily identifiable via official records, making probability sampling unsuitable. There are also no phone or address books in the region via which we could have randomly contacted potential participants. Acknowledging its biases and limitations, we felt that the snowballing method was the most suitable one as the returnees were otherwise hard to locate. Despite its limitations, we aimed at creating a sample that consists of interviewees with diverse backgrounds in order to have a broader idea of the dynamics surrounding return migration, including its challenges and realities. This strategy was pursued in three different districts also for purposes of diversity in political views, since all districts have differing political profiles. As for ethical considerations, names and any identifiable features of research participants have been anonymised. Each participant was given a consent form where they agreed to an interview that would be used for research purposes. The research assistant explained the aims of the project and received consent before he started the recording. Despite being assured of anonymity and careful processing of the data, some participants felt at unease and withdrew their consent during or after the interviews, probably due to the political climate in the KRI. The interviews were conducted with returnees, who had resided in the United States, Canada, Italy, Russia, Norway, Germany, Sweden, the United Kingdom, Denmark and the Netherlands at least for a decade prior to their return to the KRI. The participants were aged between 26 and 60 years and they had left Kurdistan between 1975 and 2002. Some of the interviewees were children, when their parents had left the region through either voluntary or involuntary migration. In this paper, we refer to them as the generation-in-between and approach their accounts under the category of 'ethnic return' suggested by Tsuda , referring a 'return' to their region of ancestral origins. The total dataset consists of interviews conducted with 17 men and 9 women. We aimed to sustain a gender balance in terms of the number of participants, yet it was challenging to find female interviewees. One reason for this gender imbalance could be that since our research assistant was male, the female participants might not have felt at ease when meeting with him one-on-one in cafes or in their homes. Secondly, as Emanuelsson shows in her study on return migration to the KRI, it is often men who first return and bring in their families afterwards. Therefore, the higher proportion of male interviewees reflects most likely the gendered nature of return migration to the region. All interviewees were given a three-month deadline to withdraw their interviews if they wanted to. It was also most often female interviewees, who withdrew their consent within the deadline. We have conducted a thematic analysis on the collected data and examined how the returnees narrated on their experiences and motivations to leave and to return, and eventually to re-return in relation to their experiences in both the host society and 'homeland'. In the first part, we discuss the forced displacement from the region, and the context of returning to a post-conflict society experiencing nation building processes and economic boom. The second part deals with pre-return and post-return experiences, whereas the last section discusses the eventual aspirations to re-return in relation to the preceding sections. --- Diasporic Homecomings to Kurdistan --- Leaving the 'Homeland' Current estimates of the Kurdish population mainly from Turkey, Syria, Iraq and Iran residing in Europe place the number of Kurdish-speakers at between roughly 850,000 and 1.3 million, with the great majority residing in Germany. Sizeable Kurdish communities also exists in the United Kingdom, France and the Nordic countries . The first wave of migration for Iraqi Kurds consisted in large part of highlyeducated middle-class men, who were politically active in their homeland and came from wealthy families. A small number of Kurdish intellectuals migrated for educational reasons prior to the 1970s, but the majority of the current Kurdish migration is conflict-generated. After 1970s, it was a variety of conflicts that drove Kurds away from their homeland. The Al-Anfal campaigns, targeting Kurdish villages and orchestrated by Saddam Hussein in the late 1980s, played an especially important role in generating migration from the region . Many Kurds were accepted as asylum seekers to different countries in Europe and beyond . Irwani states that it is impossible to find a single Kurdish family in the KRI, who had not been affected by war and forced displacement. Indeed, most participants left KRI in the context of politically unstable situation and insecurity. Only three interviewees mentioned economic reasons as their primary motivation to leave; yet such reasons were still linked to the political environment that had created a lack of human security and an increased risk of ethnic persecution. The interviewees had varying social, economic and political backgrounds, and among them some had been directly involved in political activities against the Saddam Hussein regime. As a result, their situation in the KRI grew gradually more challenging. However, interviewee accounts showed diversity rather than commonality concerning political reasons as a motivation to leave. Some mentioned that their family members belonged to either Kurdish Democratic Party or Patriotic Union of Kurdistan affiliated peshmergas, whereas others had no connection whatsoever to political movements. Furthermore, the decisions to leave contained a gendered dimension. Men had usually left alone, and only after having settled to the host country, they had invited their families to accompany them. Besides one exception, all female interviewees had left with their families. Indeed, the decision to stay or to leave was mostly taken by men. As Binder and Tošić note, gender plays an important role in decisions to leave, and can be closely connected to women's social positions as well as to the family constellation in conflictgeneration migration. In cases when the whole family left at the same time, it was usually via NGOs and international organizations, which had guaranteed the safe travel and facilitated asylum application procedures in the host country. Fleeing the country during wartime or in the midst of the on-going political crises was extremely hard, regardless of whether it was done via institutional channels or in cases when the interviewees had used smugglers. Speaking of the related risks during the journey, some interviewees had been captured, arrested or detained before arriving to the host society. The popular routes were to cross the border to Turkey, then to find ways to Greece, and from there on to other European countries. Several struggled to collect the money necessary to complete the journey, but those who could save a sufficient amount, opted to use smugglers to get out of the conflict zone. Most usually had succeeded at the first attempt, but some could only reach Europe after the second or third attempt, only delaying the inevitable departure instead of deterring it. However, social networks played a crucial role in two aspects. Some had reached the smugglers through friends and family networks, and relied on them to cover the costly journey. Migration routes were rarely straightforward and usually passed through several countries before the participants had reached the country of settlement, although a few arrived directly from Kurdistan. Those successful to pass the Turkish-Iraqi border and placed in a refugee camp in Turkey, would finally found a way to go to Canada, Australia or the United States via international organizations such as the UNHCR. The pre-existing networks in the homeland were also employed in connection to diaspora networks in the host societies to reach the society of settlement. Individual networks seem to have been the most popular factor in terms of choosing the destination country; in cases such a choice was available. Relations to homeland political parties had made it easier for the politically active interviewees to cross borders and utilize the transnational networks. On the other hand, other already existing transnational networks, such as friends and family abroad, became facilitators during the departure process and enabled to reach sometimes, although not always desired destinations. I was looking to go to England, but I didn't succeed. So I had family member, who lives in Holland, and he said Holland that is OK. I had never heard about Holland before. I had only heard about the cheese and milk…that was the only thing I knew about it. Similar testimonies show that choices for the country of settlement were more or less involuntary. Some interviewees wished to go to a specific country, like the United Kingdom, but when they didn't succeed due to economic or other reasons, they settled in another country. Testimonies also reveal that rumors circulating in the homeland had an impact on decisions where to go. For instance, the Netherlands was known for its 'Kurdish-friendly' and generous asylum policy, hence becoming a destination country for many. --- Returning to 'Homeland' The meaning of 'home-coming' was symbolically significant, since the departure had been involuntary in the context of forced displacement, whereas the return was voluntary. A majority of returnees identified the improved security situation as the main determinant for their return, explicitly referencing the fall of the Saddam Hussein regime in 2003, although they were also conscious of the growing political instability in the region. Indeed, the participants' reasons to return were most often related to what we have named 'diasporic homecoming', although such reasons were often intertwined with other motivations opened below. We categorized return motivations that referred, on the one hand, to emotional attachments to Kurdistan as home, to Kurdish culture and language and to feelings of 'Kurdishness' and, on the other hand, to the desires to contribute to the region as it had become possible in the context of improved security situation. Ten interviewees listed these issues as a primary motivation for return and for another ten interviewees it was a secondary reason. Although there was an overlap between these two motivations what could be categorized as "cultural" and "nationalist", in the first case the return was motivated by wanting to be with people, who shared common values, language and culture, while in the other one, the stress was more on selfless motivations to answer to a "homeland calling". Four interviewees had returned uniquely because they wanted to 'serve' Kurdistan at this critical moment, and referred to altruistic tone and nationalist reasons to return. When you meet Kurds from Canada, USA and Europe, you see the desire that they want to come back and do something for Kurdistan. Because when we left, we knew that we have to come back. We cannot just leave it. My motivation is to develop the industry in Kurdistan, to do something in Kurdistan to assist people and I think this is my biggest motivation. Several returnees spoke of "cultural" reasons together with an obligation to return to the homeland and to contribute to its prosperity. Some testimonies also showed that returnees came back with their political projects to contribute to transitional justice and commemoration in the KRI, and to serve as "role models" for Kurdish society: I came here to teach, I was really excited about teaching. I wanted to build memorialization projects in Kurdistan. To contribute to research, genocide awareness… I said as a Kurdish woman, I can do a little bit… just put one stone in the wall of Kurdish improvement. It makes me happy and I think we all can have a small impact and in the end we will see some changes in the society. We will be role models, I hope. The sense of duty and obligation to return 'home' and participate in the development of Kurdistan has also been identified within studies conducted on the Kurdish diasporas in different contexts, including on the second generation . Indeed, van Bruinessen has examined the relationship between exile and Kurdish nationalism and stated that 'it was exile that transformed Kurdistan from a vaguely defined geographical entity into a political idea'. The decision concerning the diasporic homecoming, motivated by nationalist or culture-related reasons, takes place in the transnational, Kurdish diaspora space. However, how Kurdish diaspora members' sense of obligation to contribute to 'homeland' development concretizes into an actual return has remained understudied. At times such culturalist and nationalist reasons became intertwined with economic motivations and business opportunities present in the region. The return migration of the Iraqi Kurdish diasporans in the post-Saddam period needs to be situated both in the context of active nation-building process but also in the context of economic development in the KRI. Economic reasons were given as the second most important motivation: seven participants claimed that they returned for better economic conditions in the KRI or they had found a better job than the one they had in the host society. For instance, some interviewees said that they found a job before they returned or they easily found one right after their arrival. Family connections, previous social networks and their newly acquired skills played a role in this. Therefore, the diasporic homecoming took place in the context of the economic boom, the rising political economy of the region and to the possibility to be able to contribute and prosper in the KRI. Indeed, the Iraqi Kurdish region experienced rapid economic growth in the post-Saddam period, partially in form of foreign investments, which led to a political stability without comparison elsewhere in Iraq. To return and to participate in the development of Kurdistan had become possible after the fall of the Saddam Hussein's regime in 2003. As Eriksson Baaz argues, return is also about giving back, which means using the knowledge acquired in exile to contribute to the development of a post-conflict homeland. The return was narrated with a consciousness of the social and human capital the returnees brought with them: the interviewees' motivations to return were informed by the eventuality of being able to contribute and make an impact in homeland development through the accumulated social capital from the host societies that could be put to good use in the reconstruction of the Kurdish post-conflict society and eventually to gain economic benefits. Lastly, family-related reasons played a significant role in decisions of return. Five interviewees mentioned that they returned due to family reasons: their elderly parents needed care and since they couldn't migrate, their children had chosen to return to care for them. This was also seen as a cultural characteristic, and therefore a duty. For few, marriage was a motivation to return and very few also mentioned that they had had to return with their parents, who had made the decision. The importance of family and relatives as primary motivator for return has been shown in previous research on conflict-generated migration . Only one participant accounted for the 'need for change' and desire for 'adventure' as the main motivation to return, whereas the overall material provided little evidence of life style-motivated migration more commonly associated with labour migrationgenerated diasporas. The interviewees of this study narrated their motivations to return in relation to the stark contrast that existed between the involuntariness of their departure and the voluntariness and freedom to return. Indeed, the experience of involuntary migration and the context in which it had taken place was inseparable of the experienced freedom of mobility manifesting in voluntary return . This study shows that such dynamics of departure and return play a significant role in shaping return decisions and ought not be dealt separately. In addition, host society experiences together with post-return experiences are also essential in determining whether returnees opt to stay or to leave again. --- Everyday Experiences Before and After Return --- Away from 'Home': Positive Host Country Experiences Different from the experiences of economic migrants, Di Saint Pierre et al. observe that refugees' migration history is 'peculiar since many of them might not have planned to migrate but had to leave their country due to force majeure'. This may not only shape the reasons to return, but also the experiences in the new society of settlement. More than half of the interviewees accounted that their first impressions in the host country right after arrival had been a cultural shock and language problems, but also feelings of strangeness and loneliness that persisted during the first months. Several had also felt 'free', 'impressed' and certain that they had made the 'right decision.' One major issue determining the general well-being was the reception of the asylum status and welfare benefits. On the other hand, participants, who had spent a considerable time at a refugee camp, struggled and depicted their situation in more negative terms compared to those, who had not stayed in refugee camps. The traumas of the conflict clang to the interviewees for a long while: I was shocked, I couldn't compare the place I lived in, and the new place, which was clean, there were flowers in the streets. In the place where I used to live in there were daily bombings by Saddam, because of the bullets sounds I couldn't sleep. In Germany during nights I asked myself 'why there are no sounds [of war]? While the legacies of war lingered in their memory and were visible in the accounts, the participants had evaluated their new situation as an act of fleeing from the war. While acknowledging that hardships were merely a part of a transition period, some got used to the new environment more easily than others, namely those interviewees, who had arrived fairly young to the country of settlement. The generation-in-between interviewees acknowledged the advantage of arriving young, compared to their parents, who struggled considerably. Similar to previous literature on the Kurdish generation-in-between , the interviewees felt more 'at home' in the society of settlement compared to their parents. Having gotten there at a very young age, we integrated very quickly, me, my sister and brother. So our culture and our norms and values were more Dutch or English than Kurdish, because we arrived there at such a young age. It took a long time for my parents to let go of the Kurdishness. First-generation participants also felt this divide between them and their children, and one interviewee even mentioned that his biggest fear had been the 'losing Kurdish culture' in the host society. For this reason, him and his family had attempted to strengthen ties with their contacts back in Kurdistan, but had also taken measures by sending their children to a Kurdish language course in order to facilitate their adaptation in case of return. It is noteworthy that the overall experiences across the host societies were positive, especially for those settled in the United States, Canada and Sweden. Di Saint Pierre et al. suggest that the social and cultural isolation in the host country foster return decisions. Contrary to this, the majority of participants finally returned due to other reasons than negative experiences in the host society. Only a few interviewees mentioned that they or their family members had experienced discrimination, in the context of rising xenophobia after 9/11 , but also due to conflictual inter-ethnic relations in the host society: I haven't experienced discrimination but my parents have… based on their religion, especially after 9/11. For me, the discrimination was based on being a Kurd, but not by Canadians. By Arabs and some other groups… I haven't experienced it personally, but my mom, she used to wear a scarf and I remember that she received comments about her scarf quite a few times. They told her go back to her country in Holland. The rise of xenophobia in the post-9/11 era was reflected in interviewees' experiences in the host countries, yet such negative experiences were not listed as a motivating factor to return. Whereas earlier hypothesis on return migration associate it with failed integration, more recently scholars have shown that the relationship is not that clear-cut. For instance, de Haas and Fokkema examine the relationship between positive integration and negative return intentions in their study on four African migrants groups in Spain and Italy. They show that structural integration has generally a negative effect on return intentions. However, when looking at particular indicators more specifically, they notice that education has positive effect on return intentions, therefore countering the more assimilationist and neoclassical interpretations according to which negative integration would lead to return migration. This was also the case of Iraqi Kurdish returnees, who defined themselves as 'wellintegrated'4 . Whereas the lack of language skills and integration in the labour market had delayed their adaptation to the host country in the earliest stages of settlement, their situation had improved with time. After the first cultural shock and struggles to adapt, the interviewees listed several benefits of their host societies, including education, employment, health care, rule of law, justice and human rights, and the overall human security in the countries of settlement. Furthermore, many expressed feelings of gratitude to the host societies that had provided them with welfare services and opportunities: Indeed, more than half of the interviewees acquired significant human capital abroad, including high school diplomas as well as BA, MA and PhD degrees in engineering, philosophy, linguistics, management, medicine and law. Only one interviewee mentioned that he couldn't get into a program, while three others said they were not interested in acquiring degrees. As Van Houte rightly suggests, not all migrants benefit from their migration experience in these terms. However, some of the participants had already started from a privileged position and managed to accumulate more social capital in the host society, whereas others struggled more. As Tsuda states 'it is a combination of external host society reception and the human and social capital that immigrants possess that determines their socio-economic success and integration.' However, accounting for the relatively high number of well-educated returnees in the sample, it seems that the human and social capital that has been acquired in the host societies has also enabled to return . A majority of the interviewees felt that the successful integration actually played a facilitating factor to return to Kurdistan, as the return but also the re-return were considered less risky due to the accumulated social and human capital. Another major facilitating factor for return were the transnational networks and contacts towards Kurdistan . Very few participants were active in diaspora organizations, and had kept ties to homeland Kurdish political parties. One had chaired a diaspora organization; another one had founded various Kurdish NGOs in different European cities, and the rest occasionally attended protests and seminars organized by diaspora organizations. However, they had maintained less political transnational ties to Kurdistan when in host societies, by sending economic remittances or maintaining frequent contact with family members and relatives. Conway et al. have argued in the case of Trinidadian returnees that repetitive visiting plays a role in decision to return. A majority of the interviewees also stated that they started visiting the KRI more frequently in the post-2003 era despite the sectarian violence that characterized the rest of Iraq. Carling and Pettersen have presented a conceptual framework to better understand the triangular relationship between integration, transnationalism and return migration. Based on their study on ten major migrant groups in Norway, their analysis shows that migrants with strong transnational ties and weak socio-cultural integration have strongest motivations to return, but that it is the relative strength of integration and transnationalism that bears upon motivations to return. In other words, people who are strongly integrated and have strong transnational ties are equally likely to return as people who are weakly integrated and have weak transnational ties. In this study, the interviewees' self-reported high levels of integration together with strong transnational ties seem to support Carling's and Pettersen's hypothesis. As we will show later, this can also play a role in plans to re-return. Overall, whereas the involuntary departure became contrasted to voluntary return, also the positive host society experiences quickly became contrasted to challenges that returnees encountered in the KRI. Meeteren et al. posit that post-return experiences are shaped by returnees' 'human capital, transnational contacts, social networks, socio-economic integration in the destination country, legal status, and gender' . They also call for a contextualized theory and analysis on post-return experiences. We agree with the authors and suggest that besides taking into consideration the societal or political context in which the return takes place, both pre-return and post-return experiences play a role in determining whether diasporans' opt to re-return or stay in the 'homeland'. Whereas reuniting with relatives left behind and resettling in a familiar cultural environment were mentioned as the main benefits of return, more than a majority of interviewees mentioned that they had felt 'disappointed', 'disillusioned' or 'sad' after return. The level of disappointment also needs to be understood in relation to returnees' expectations related to 'diasporic homecoming' and to their motivations to contribute to homeland development. They felt that Kurdistan was missing the opportunity to become a democratic country in the Middle East and not using its full potential despite its economic means to do so. Some returnees decided to return after having heard positive things from friends, family and acquaintances, but were now disappointed with the current situation in Kurdistan: I was sad because the Kurdish TV channels lied to us. They show us just the beautiful views of Kurdistan. --- Challenges of 'Diasporic Homecomings' I am so happy to see my family but the situation in Kurdistan disappointed me. [..] Life is more difficult than the UK. There is no law but a high level of corruption. Several empirical studies point towards returnees' negative experiences with corruption and local power relations, feelings of frustration and disappointment in homeland context . This is also the case with Iraqi Kurdish return migration, as shown by Emanuelsson and more recently by Paasche . For instance, Paasche has found out that in many returnee narratives, KRG's ruling elites appeared as above the rule of law and ruling the region through neopatrimonial patronage. He also suggests that returnees compare their return experience to pre-return experiences in the host countries' political spheres that they perceive relatively more transparent and free. As he puts it: 'Exposure to a different political model abroad is seen as fomenting discontent with governance in Iraqi Kurdistan' . The comparison between the KRI and the host countries, including the freedom of speech, had led to further disappointment. Indeed, corruption, political instability, endurance of the tribal system and nepotism were mentioned as the main sources of disappointment also among the interviewees of this study. Tsuda is right to suggest that it could be the same homeland but the 'ethnic homecomings' may differ according to class, gender, status, and social capital among other things. Some found it hard to find employment to their liking without the locally apt forms of social capital, networks and connections. The lack of local forms of social capital were manifest particularly in form of having the "right" political networks and affiliations, and belonging to a family that supported a specific political party. A returnee from the education sector told the following: The challenge is that in the Ministry [of Education], they do not give me a job, they just give it to party members. And I am afraid of being fired from my job because I criticize the political parties too much. "There are too many obstacles. People need to depend on their connections and most things are based on where you have relatives." Some others admitted that they are having 'moral dilemmas' in terms of adapting to the homeland culture after so many years. Their 'Western' lifestyle included certain aspects such as respecting the rule of law, transparency in terms of governance as well as equality of opportunities. Indeed, the 'home-comers' are not always welcomed by the local population that stayed behind. The relations between the locals and the returnees might become tense especially if they are perceived as outsiders . The KRI was not considered to offer an enabling environment, and several participants complained that their efforts were looked down if not suppressed by the locals. During the first few years of return there was little contact with the locals. Some interviewees did not define their contacts with the local population as conflictual, but admitted that there was isolation: they did not mix much and had their own social spaces. However, some did mention perceived discrimination and hostile behaviour. Two interviewees specifically mentioned that they had been accused of fleeing the country when the situation had been bad and that they had returned when this had changed. One interviewee who had recently returned from Germany said that he was perceived as a "traitor" because he had left when "Kurdistan needed him the most". Another interviewee from the USA testified that some locals had told her that "now that Kurdistan has money, you are coming back from USA and Europe." For half of the interviewees, there had been no tension between the locals and the new-comers. Although agreeing upon the potential of returnees to make significant economic and political contributions, another half of the returnees had experienced that the locals saw them as a threat to their jobs and status and considered their interventions and education too 'Western', 'foreign' or 'superior'. For example, one returnee had pursued his career as a university lecturer in the KRI, but felt that the work ethics were too different: In the first two years of my employment, I worked as I was working in Denmark. Therefore, there were tensions sometimes and some professors tried to sack me. Even outside work place, I had tensions with other people. Female interviewees accounted that they had experienced more open and freer gender relations in their host countries, thus leading to more problems to adapt compared to their male counterparts . As one stated: 'It is just a country for men here, not for women'. She reflected on her life in the United Kingdom, in comparison to her recent experience in the KRI, as the following: I've lived my whole life in there [England] so I have many positive and negative experiences in my life. So coming to Kurdistan I realized that it was a positive experience because first of all as a girl… as a single woman you are free… you are free to do what you want and where you want to go…so there is nobody who tells you don't go out, don't work get married you know there is no pressure over there. There is no pressure when it comes to social issues. I just feel that women there are more independent, they are encouraged to be independent, they are encouraged to work, to make their own living, not to care about what people say about them…or whether they get married or not. Another interviewee also had a story to tell: One day I was wearing a short skirt and the taxi driver told me he will not pick me up. For women it is difficult to live here… My plan was [upon return] to work on creating gender equality and to motivate women to be as free as men. I worked for that… but the government did not respond. It did not support the plan. Although a majority of the interviewees, not all had experienced disappointment and disillusionment upon return. Some contrasted the prevailing realities in Kurdistan with the situation under the Ba'ath regime where there was the constant fear of extinction. In such accounts, nationalist feelings and emotional attachments seemed to prevail over the political and economic expectations. However, the current war against IS and the international conundrum also made them feel insecure in the KRI, especially since after their return, the situation had rapidly deteriorated, including the economic situation. Drawing from the transnational frame, Van Houte andDavids emphasize 'the importance of defining sustainability of return through the use of the concept of mixed embeddedness, and the different factors that influence this embeddedness'. They understand the term 'embeddedness' in terms of an individual finding his/her position in the society and feeling a sense of belonging within that society, whether it is in form of economic , social or psychosocial embeddedness , or interrelatedly them all. In this way, they link migrants' experiences in the host society to the everyday epistemologies of returnees in the post-return context. Similarly in this case, the everyday epistemologies prior to departure , after the departure and settlement in host society and after the diasporic homecoming all together shaped returnees' reflections on whether to stay or to leave again. Such reflections on return as well as on re-return also contain a gendered and generational dimension, in the sense that prereturn and post-return experiences can be quite different for men and women, for firstgeneration migrants and their descendants, as well as intersectionally so. --- Reflecting on the Re-Return Diasporas are often treated as agents of development and peace-building, and some states are known to have drafted specific diaspora strategies and ministries to attract the diasporic return . However, whether the home country creates an enabling environment for such interventions is the key to understand the dynamics of 'diasporic homecomings' and the eventual contributions it can generate. Although the KRG officials repeatedly welcome the return of diaspora Iraqi Kurds, the general conception among the returnees was that the KRG was not able not create an enabling environment for them to contribute to the development of Kurdistan. All the interviewees, without an exception, stated that the KRG had no policies for welcoming or even encouraging diaspora members to return. Local forms of networks and social capital seemed to play a huge role when it came to turning the return experience into a 'success story', especially in the realm of investment and political positions. As mentioned by Åkesson and Eriksson-Baaz , 'successful return migration is not primarily dependent on the various forms of social, cultural and economic capital obtained abroad, but on the various obstacles posed by the structures encountered upon return and the returnees' ability to transform the migrant capital they have attained.' A majority of the interviewees' accounts reflected that the return was not considered as a permanent, one-way move to the 'homeland', but that it was an on-going, open project towards future, and one that would eventually involve continuous transnational circulation . Concerning the possibility to re-return to the host country, eleven interviewees out of twenty-six mentioned that they were planning to move back within a short time period, and six had settled in Kurdistan permanently. Among them, some found it difficult to move again due to old age or because they were married to somebody local. One interviewee mentioned how hard the situation was for her children in Kurdistan. Despite being aware of the challenges she might encounter as a woman, she says that she did not pay enough attention to the situation of children upon return: To be honest, especially when I see my kids are suffering in school, as a mother, of course you rethink about return. Being a woman in this society is another issue…but that is a personal issue. That was my choice, I decided to come back but my kids… they had no choice. Five interviewees said they would decide according to the evolving situation in Kurdistan, especially if the war with IS continued or if the economic situation deteriorated. For instance, the economic situation between the moment interviewees returned and when the interview were conducted had changed drastically. Since 2014 the KRI has experienced an economic crisis one after another, partially due to the budgetary cuts to the KRG by the Iraqi government, which might generate re-return from the region. Indeed, a total of sixteen interviewees had either decided to leave or were thinking of re-returning. Four interviewees instead stated that they sometimes thought about the return, but at the moment of interviewing, they had not made any decision concerning it. When asked whether they regretted of having returned, a little more than half either did or had mixed feelings about it. The rest did not regret their return . My feelings are paradoxical. Sometimes I wish I did not come back, but another time I will say, coming here was much better than staying there. So many things have changed in terms of construction, but people's minds are still old. The interviewees' accounts showed that there is a close relationship between transnationalism, on the one hand, and return intentions, decisions, post-return experiences and the possible re-return, on the other hand . A majority of the interviewees fostered attachments, travelled or intended to travel to the host countries on a regular basis. Only one interviewee talked about 'burning bridges'. One of the main reasons for the maintenance of transnational ties were the family members and friends abroad as well as established businesses in the host country. Also, the accumulated human and social capital from the host country was considered to enable a relatively risk-free re-return to the host society. Indeed, the challenges of reintegration can in some cases encourage the returnees to 'return' to the host society or to opt for a transnational life arrangement between the host society and the homeland . Four interviewees suggested that re-return or circular return would be a preferred strategy in the current context . However, most saw KRG statements that aimed to attract return migrants to the region as a show of 'goodwill', since the realities were shadowed by corruption, nepotism and political instability. Returning with great aspirations and sometimes with expectations of a 'hero's welcome', returnees were reevaluating their decisions. Similarly to Iaria's study on Iraqi returnees, post-return transnationalism should not be considered as separate from pre-return transnationalism. Instead, the transnational livelihood strategies before return should be seen as a continuity of post-return strategies. This also applies to the decisions related to such strategies concerning return and re-return that need to be analyzed in relation to the socio-political context they take place. In this case, retaining a base in both countries prevailed as a preferred strategy. The citizenship in a EU country, United States or Canada enabled great mobility and facilitated the decision to return and to take the risk, similarly to Mortensen's findings, as well as to re-return to the host country if the return failed. The citizenship also facilitated the arrangement of transnational family life as in most cases the interviewees had left their family members in the host country to wait that they had settled securely in Kurdistan. This study's findings show that interviewees' motivations to leave Kurdistan stemmed from a combined lack of political, social and economic security, and the return was motivated by increased security situation in the KRI. Regardless of positive host society experiences, they had decided to return to Kurdistan that was undergoing an economic boom and intense nation-building processes, the latter still continuing strong. This was also reflected in return motivations that were mostly nationalist/cultural, economic and family-related. Referring to their return as 'diasporic homecoming', the returnees wished to contribute to the development of the KRI. Social capital acquired in the host society, host country citizenship that provided increased mobility and transnational capital facilitated the decision to return to the KRI. However, interviewees were at times lacking local forms of social capital to reintegrate and regardless of the symbolically significant 'diasporic homecoming', they experienced a mismatch between the expectations and realities stemming from nepotism, corruption and more traditional gender relations that became contrasted with positive host society experiences. The factors that had facilitated the return decision were also felt to provide a security network in the case of an eventual re-return, considered by a majority. --- Conclusion As Åkesson and Eriksson-Baaz underline, 'return is emerging as a key issue in the most recent policy documents on development in the European Union as well as in various member countries.' Other organizations such as the UNHCR also promote return migration as they see repatriation as a vital part of post-conflict reconstruction. As Sinatti suggests, discussions on return migration actually parade as a triple-win scenario, where the sending states benefit from returning human capital and skills, host countries benefit from temporary workforce and the returnees achieve better status in the homeland thanks to their migration experience. In the Iraqi Kurdish context, the issue has drawn significant attention from international organizations such as the IOM, state-linked actors and development aid agencies that have also started investing in voluntary and assisted return programs for facilitating diaspora mobility towards the KRI . Although discursively, homeland political actors reference the Kurdish diaspora's contributions and call for the diaspora to "return", little arrangements are put in place to facilitate diaspora interventions. This study's broader aim was to map the field for policy-making and future studies on return dynamics and post-conflict reconstruction. The findings support the observation by Brinkerhoff that the homelands need to create an enabling environment for diasporas in order for them to contribute to homeland's development and prosperity. Interviewees claimed that institutional support they received was scarce, referring to the lack of KRG-led policy in this matter. This study shows that returnees' experiences both preceding and following the return bear on their decision-making processes to stay in the 'homeland' or to opt for a re-return. On the basis of this study's findings, we suggest that reintegration measures in case of voluntary return would better: 1) recognize the returnees' transnational human and social capital and knowhow and how that can be transformed into local forms of capital; 2) take the gendered and generational aspect of returnees' pre-and post-return experiences into account, the possible mismatch stemming from different gender relations, rule of law and institutional practices, and how that affects plans for re-return; and 3) acknowledge that even though diasporans might return for "ethnic" or nationalist reasons, it does not automatically lead to sustainable and long-term return. Voluntary returnees' transnational mobility and life arrangements rarely fit into the classical understanding of return to homeland as a permanent condition. Therefore, reliable data is needed on the number of returnees, re-returnees and those, who have opted for circular migration to assess to what extent the current return of diaspora Kurds is sustainable. The more recent political developments, namely after the independence referendum, create new dynamics for engagement between the KRG and its diaspora. However, in case the voluntary return of highly-skilled diaspora members does become sustainable, it will have a vital impact on post-conflict reconstruction and eventual state-building in the KRI. The social and human capital of returnees increases in importance for the KRI's stability and survival in the midst of the on-going political conflicts and economic crises in the region. --- Voller Y The Kurdish liberation movement in Iraq: from insurgency to statehood. London: Routledge. --- Table 1 -Interviewees by age, year of departure and the country of settlement 5 5 Their date of return and the province that they currently live is not given for the purposes of anonymity. Our experience shows that these markers may make the interviewees identifiable. --- Age and gender Year

Iraq (KRI) in the post-Saddam period and provides a contextualized analysis of the returnees' experiences in a rapidly shifting geopolitical situation in Kurdistan. It specifically focuses to examine how diasporans' motivations to return as well as their plans to re-return are shaped in relation to their experiences in host societies and in 'homeland'. Drawing from qualitative interviews, it shows that Kurdish diasporans' return can be characterized as 'diasporic homecoming' as it is motivated by the desire to contribute to the economic and political development of the KRI. However, the mismatch between expectations and 'homeland' realities combined with positive experiences and social capital accumulated in the host country makes plans for re-return more foreseeable and less risky.

Electronic cigarettes are an emerging form of nicotine supplementation around the world. 1 Compared with cigarettes, there is no standardized governmental policy regarding restrictions and guidelines for the use and availability of ECs. 2 It has been well documented that tobacco use is detrimental to aviators. 3,4 Because of the relatively new popularity of ECs, few data are known regarding their use and impact in the aviation community. There is little information on EC use within the military. A recent study found that approximately 5% of U.S. Air Force recruits, most of whom were under 20 yr of age, were actively using ECs. 5 It was also found that the prevalence of use in that population was rising. Among the population of recruits, 23.9% of EC users also smoked cigarettes. 5 Nationally, rates of trying ECs are relatively low, varying from as low as 3.3 to 12.6% with the highest use among current cigarette smokers. 6,7 Tobacco use has been linked to many diseases such as lung cancer, pulmonary diseases, emphysema, cardiac ischemia, and peripheral vascular disease. Cigarettes account for over 480,000 U.S. deaths annually. 8 Many efforts have been made to develop new methods to help people quit tobacco use. ECs have been touted as a new method of tobacco cessation. 9,10 One reason for the promotion of ECs in cessation is that they can be used in the place of cigarettes as a harm reduction strategy. 9 Questions are being raised concerning the assumed safety and lack of harmful chemicals in electronic cigarettes. Instead of known carcinogens, ECs have a wide range of chemicals of unknown biological consequence. These chemicals include propylene glycol, glycerol, various flavoring compounds, nicotine, carcinogens, other undefined toxic chemicals, and ultrafine particles. 11,12 From 2010 to 2014, poison control centers have observed that EC-related calls have increased from an average of one per month to 215 per month. 13 Emerging evidence is challenging the assumption that EC use is an effective tool for smoking cessation. 14 Although some evidence suggests that ECs may aid in cessation by reducing the number of cigarettes smoked. 15 A meta-analysis of the usefulness of electronic nicotine delivery systems, such as ECs, in smoking cessation was inconclusive. 16 Some studies have shown that EC users concurrently smoke cigarettes instead of quitting. 17,18 In fact, some evidence suggests that EC users may actually be less likely to quit smoking than those who do not use ECs and have greater nicotine dependence. 11,17 The motivation for simultaneous use may be because of social pressures, smoking restrictions, and ease of use. There are many components to ECs, chief among them is nicotine, a chemical that on its own has many harmful sequelae related to its use. Nicotine, independent of cigarette or EC use, may cause poor decision making, increased impulsivity and risk-taking behavior. 19 EC users have been found to be at high risk for many health problems such as reduced pulmonary function. 20 In addition, side effects that have been reported with EC use include vomiting, nausea, and eye irritation. 13 Although widely acknowledged as a hazard to aviation, there are no strict limitations on the use of tobacco products by pilots other than during flight. 4 In order to eliminate the harms of tobacco use, aircrew personnel may pursue alternative nicotine sources such as ECs. Naval aviation is just a small subset of all aviation but it adheres to perhaps the most rigorous medical standards found throughout the world of aviation. U.S. Naval aviators are known to be very health conscious and to make excellent decisions regarding their physical fitness and lifestyle choices. 21,22 Because of their high health consciousness, aviators function as an optimal model for health behavior decision making. Although there have been no conclusive studies of the health outcomes for all aircrew , all aircrew are held to similar physical and mental standards. Currently, there is no guidance or understanding of the use or impact that ECs pose to aviators and aircrew personnel. Considering the potential health consequences of EC use, it is essential for authorities such as the Federal Aviation Administration and other governmental and military organizations to gain a better understanding of the prevalence of ECs in the aviation community. The intent of this study is to not only assess the usage of ECs in the aviation community and the U.S. Navy but also to gain insight into unique risks that may be posed to the greater military population. --- METHODS This study involved 977 volunteer U.S. Navy personnel composed of individuals working in a flying job and not . Aircrew include pilots , naval flight officers, enlisted aircrew persons, and flight surgeons. Non-aircrew included individuals who identified as working in maintenance, administration, or other support, or "other." The study participants were sailors who completed an annually required periodic health assessment at the Branch Health Clinic Jacksonville Department of Aviation Medicine. This clinic nearly exclusively cares for naval aviation units composed of aircrew and non-aircrew personnel. Approximately 200 PHAs are conducted at the clinic every month. The data were collected and analyzed over an 11-mo period in 2015-2016. All completed surveys were included in the analysis. The survey titled "Assessment of Electronic Cigarette Use in the Aviation Community" was attached to the PHA paperwork given to patients who presented to clinic for an annual PHA. The invitation to participate and instructions were noted at the top of the survey. Individuals who chose to participate filled out the form and either left it attached to the packet or turned it into a medical assistant. This protocol was approved by the Institutional Review Board at Naval Hospital Portsmouth located in Portsmouth, Virginia. The survey questions included non-personally identifiable demographic information. Prevalence data were assessed by asking participants about ever trying ECs, frequency of use, and when was the last time an EC was used. Participants were assessed similarly regarding cigarette use. Participants were grouped into demographic categories that included age, sex, military rank , years of military service, highest level of education obtained, and current job . Military rank is equivalent to paygrade and is an alternative marker of income level. Participants who reported any EC or cigarette use within the past 30 d were considered current users. EC users were considered heavy users if they vaporized on 10 or more days in the past 30 d. Excessive use was considered to be use of six or more fluid cartridges on a typical day. Cigarette use was categorized similar to EC use in that heavy use was defined as smoking on 10 or more days within a 30-d period and excessive use was defined as smoking six or more cigarettes per day. Continued use is defined as participants reporting ever using EC or cigarettes in the past and also reporting any EC or cigarette use within the past 30 d. --- STATISTICAL ANALYSIS The analysis was completed using SPSS, version 23, and Microsoft Excel. Descriptive statistics were computed. Inferential statistics were conducted that included the Chi-square tests for binomial variables. The Chi-square test was also used to determine if there were any significant associations within the data collection time periods and several of the sample demographics, such as time-inservice and EC use. Multinomial logistic regression models were fitted to evaluate the factors and contributors to the use of ECs and cigarettes in the aviation community. Missing values were excluded from individual calculations. Unless otherwise specified, reported EC and cigarette use calculations include dual use . The level of significance was set at α = 0.05 with a corresponding confidence interval of 95%. --- RESULTS The response rate for the survey was approximately 44%. The sample population was mostly male ; older than 25 yr of age ; enlisted ; had 10 or fewer years of military service ; and approximately half were aircrew . All but seven of the sampled population had at least a high school diploma. Most of the participants had less than a college bachelor's degree and the largest single subgroup had completed some college coursework . The comparable overall Navy workforce demographics are 83.1% enlisted, 73.8% junior enlisted, 82% male, and 77% with less than a bachelors' degree in education. 23 A large portion of the sample population had tried ECs ; 9.3% were current users, of which, 59.3% were not also current cigarette smokers. The continued use rate among all EC users was 30.0% and the rate among those only ever trying ECs was 30.6%. Among current EC users, 3.7% were considered to have heavy monthly use and 52.7% were considered to be excessive daily users. Stratified demographic groups demonstrated unique risks for EC use. Enlisted personnel had a higher prevalence of current EC use compared with officers with junior enlisted followed by senior enlisted being the largest user subgroups based on paygrade . Individuals with 10 or fewer years' TIS were more likely to have tried ECs but those with more than 10 yr TIS were more likely to have tried cigarettes . Having a bachelor degree or higher was protective against currently using ECs . Similarly, being in a flight status was also protective . Among the aircrew personnel, the continued EC use rate was 22.1% which was 1.35 Demographics and behaviors of respondents presented by variable with counts and percentages with χ2 calculations used to determine significance. Boldface indicates statistical significance . Counts are the actual number of respondents for each question within each characteristic subtype. "Ever tried" variables include individuals from the other "try" categories in the calculations. Individuals who reported dual use were excluded from "Only EC User" and "Only Cigarette Smoker" categories. 1 Population of those who tried EC among those who tried cigarettes. 2 Population of EC users among current cigarette smokers. smokers was 27.3% and the rate among those only ever trying cigarettes was 14.8%. The continued EC use rate of 30.0% was only slightly higher than the continued cigarette use rate of 27.3%. The estimated odds of current EC use were nearly five times higher for those who were current cigarette smokers than those who were non-smokers . Those who had ever tried cigarettes were almost 12 times more likely to try ECs than those who never tried cigarettes . Additionally, 12.1% of current EC users had never tried cigarettes, although 40.7% were current smokers . ECs were used at some point as a smoking cessation tool for 43.6% of current EC users , 21.6% of current smokers, and only 5.6% of former smokers. Logistic regression demonstrated that education significantly predicted ever or current use of ECs or cigarettes . Similarly, paygrade predicted current EC and cigarette use as well as ever using ECs and ever using cigarettes . In both education and paygrade, the lower levels were more likely to be current EC users and cigarette smokers. No significant misuse of ECs or fluid was observed. However, small cases of misuse were noted that included drinking, tasting, and touching the fluid, using it in some way not listed as well as vaporizing something other than ecigarette fluid. Enlisted personnel and men were more likely to be heavy monthly EC users . Men were also more likely to be excessive daily cigarette smokers , while enlisted personnel were more likely to be heavy monthly cigarette smokers . No significant trends were found regarding demographics associated with excessive daily EC use. The study was conducted over a period of 11 mo. A time trend analysis revealed no significant differences in the basic demographic factors, EC use, or cigarette use during the study period. --- DISCUSSION These results demonstrate a unique snapshot of EC use in a select population of U.S. Navy personnel. This study was able to capture previously unknown risk groups for EC use. These results are important because of the comparisons that can be made between EC use and conventional cigarette smoking. There was a high rate of individuals who had tried both ECs and cigarettes but dual current use was much less prevalent . The crude rate of continued EC use after ever trying ECs was higher but not notably different than trying cigarettes and continued cigarette use . The rate of continued use among individuals who only ever tried ECs was twice that of the continued use among individuals who only ever tried cigarettes . The comparable percentage of continued use among those who ever tried ECs and those who ever tried cigarettes provides insight into potential addictive properties of ECs. Although addiction is a concern, it is possible that the increased continued use may be a function of product novelty or perceived safety. Notably, 43.6% of current EC users, 21.6% of current smokers, and only 5.6% of former smokers, at some point, used ECs to help quit smoking. One hypothesis for the high cessation intention rate among current EC users is that those individuals may have simply replaced or augmented cigarette use with ECs. Studying EC and cigarette use specifically among aircrew provides a unique perspective into the emerging trend. The aircrew personnel in this study were of varying education levels, ages, and paygrades with both genders represented. Across nearly every variable studied, the non-flight community or "normal" group had greater odds of ever using ECs or cigarettes, being a current EC or cigarette user, dual trying ECs and cigarettes, and had higher rates of continued use after ever trying ECs or cigarettes. These findings are important because they suggest that there are choice differences between the "healthy" flight-duty personnel and the "normal" population. Considering this, one concerning finding is the lack of statistical difference found between aircrew and non-aircrew in regard to continued use of ECs after ever trying. One would expect that the difference in continued EC usage would follow the same trend as other study variables, where aviation status is a protective factor, but it does not. The lack of difference may indicate unique properties with ECs that overcome the social and cognitive motivations guiding health choices. The significant correlations between EC and cigarette use by age group found in this study agree with other large studies. In this study, we identified that current EC use was higher among young individuals. This difference in prevalence among age groups may be a function of behavior adoption models with younger persons generally composing a greater proportion of the early adopter component. The differences in prevalence for smoking and EC use among this study's demographics suggest some implications of the social determinants of health . Social determinants such as education and income have been correlated with health behavior on countless occasions. The income of participants can be indirectly studied by paygrade distributions . As previously noted, enlisted paygrades had greater prevalence of ever trying and currently using ECs and cigarettes. Similarly, less than a bachelor's degree in education predicted participation in all use behaviors in this study. This study completed a novel comparison of EC use with that of cigarettes. The findings indicate that there is still a high prevalence of cigarette use within the U.S. Navy aviation community despite cessation efforts. The findings also suggest that EC use may be higher than previously assumed and used by a greater diversity of individuals than previously believed. Comparisons were made using rates of continued use after trying either cigarettes or ECs, with this study indicating that the risk of continued use after trying ECs was comparable to the risk of continued cigarette use across demographics categories. --- LIMITATIONS This study is unique in both its cross-sectional assessment of EC use and its ability to select "healthy" and "normal" populations within the study group. The study had a relatively low-response rate that allows for potential self-selection bias because of the voluntary nature of the survey. The possibility of self-selection may have skewed the results to over-represent or under-represent EC and cigarette use. Although this study provides valuable insight into current EC and cigarette use prevalence, there are questions as to the generalizability of the results. Active duty U.S. Navy personnel vary from their civilian counterparts in many often-unaccountable ways. Also, while the study population was demographically similar to the larger U.S. Navy, it does not compare equally with the other services or to the civilian population. Attempts were made to compensate for these demographic differences by obtaining intervariable prevalence and risk information. Obtaining insight into the change in prevalence of EC use may be achieved in larger more diverse populations and over a longer study period. The questionnaire was limited in that time intervals between first use and current use were not assessed. Although paygrade and education can function as surrogates for traditional SDH measurements, future studies may benefit from self-reported income and education levels. Additionally, information related to partner EC and cigarette use as well as ethnicity data may elucidate trends within future studies. --- CONCLUSIONS The goal of this study was to assess the current prevalence of use and misuse of ECs in the aviation community. Insights were gained into comparable use with cigarettes and use among diverse populations. Indications of essentially equivalent continued use of ECs compared with cigarettes suggest that ECs may have a comparable addictive potential to cigarettes. The prevalence of ever trying and current EC use may be higher than previously thought. The high prevalence of EC use among specific groups suggests SDH implications. Studying the long-term consequence of EC use in the general population is important and communities of healthy working individuals, such as naval aviation personnel, may provide a unique avenue to explore these outcomes. Benefits would likely be gained from future surveillance and prospective studies as well as inquiries into motivations and perceptions of EC use.

Introduction: Electronic cigarettes (EC) are an emerging form of nicotine replacement that has had a discernible increase in prevalence in the general population. Little is known regarding EC use among different military demographic groups or the extent of influence that social determinants of health may have on the behavior. The purpose of this study was to assess the prevalence and correlates of EC use in a select population of active duty U.S. Naval personnel. This study is unique in that it allows for EC behavior comparison between a traditionally healthy demographic (aviators, a subset of aircrew) and a representative general military population sample. Materials and methods: Cross-sectional survey data were collected anonymously and analyzed in 2015-2016. Active duty Naval personnel (n = 977) were asked about ever trying ECs, frequency of use, and when was the last time an EC was used. Participants were assessed similarly regarding cigarette use. Descriptive and inferential statistics as well as multinomial logistic regression analyses were conducted using categorical and ordinal variables assigned to usage and demographic factors. This protocol was approved by the Institutional Review Board at Naval Hospital Portsmouth located in Portsmouth, Virginia. Results: Within the study population, 31.4% have tried ECs, 9.3% were current users, and only 3.8% were dual (EC and cigarettes) users. EC use was significantly associated with paygrade (enlisted), primary job duty (non-aircrew), and education (less than a bachelor degree, p < 0.001, p < 0.01, and p < 0.001, respectively). ECs were used at some point as a smoking cessation tool for 43.6% of current EC users (p < 0.001), 21.6% of current smokers, and only 5.6% of former smokers. Continued EC use after ever trying ECs (30.0%) was only slightly more prevalent as continued cigarette use after ever trying cigarettes (27.3%). Smokers were nearly five times more likely to currently use ECs compared with non-smokers. Trying cigarettes was associated with nearly 12 times the risk for trying ECs compared with those who never tried cigarettes. No significant misuse of ECs was noted; however, several cases of drinking, tasting, and touching EC fluid were reported. Conclusion: This study is unique in that it examines the use of electronic cigarettes among selected healthy and baseline groups within the active duty U.S. Navy population. The current prevalence of EC use among active duty personnel is much higher than previously thought. Continued use of ECs after ever trying them appears to exceed that of cigarettes even among healthy populations such as aircrew. The findings of increased risk of EC use among those with lower income and less than a bachelor's degree suggest social determinants of health implications. This study sheds new light on EC use, characteristics of use, addiction implications, and highlights concerns for a growing health risk behavior.

Introduction Traditionally, the end user was mostly regarded as a passive recipient of products of scientific research, but after the "participatory turn," more active involvement of these users in the innovation process has been sought . For an adequate social embedding of scientific innovations and an increase in the trustworthiness of science and technology institutions, it is necessary to take into account other kinds of expertise than just technical-scientific perspectives . Upstream engagement exercises, such as public debates, focus groups, and interviews, are supposed to open up the innovation process to incorporate future users' needs and wants before it is too late to make fundamental adjustments. Although upstream engagement is a contested notion, a workable definition is "dialogue and deliberation amongst affected parties about a potentially controversial technological issue at an early stage of the research and development process and in advance of significant applications or social controversy" . This implies that upstream engagement exercises need to be well-timed. Early on in the innovation process, everything is still potentially open to users' feedback, but on the other hand, there may be too many uncertainties and too little concrete information on which they can base their feedback. This information may become available more downstream in the innovation trial, but then the product has become so entrenched in institutional commitments and decisions regarding its techno-scientific development that it is too late to make any drastic changes. This problem has been termed the Collingridge dilemma . In addition, innovators and nonexpert stakeholders may have different ideas of what counts as well-timed. For innovators, this may be directly after a proof of principle for a particular innovation has been achieved. Then there is a concrete cause for involving affected parties. For users, however, this may be beyond a point where decisions that are relevant for them are still open. For them, well-timed may mean even before any research has been undertaken. In this article, we show that fruitful upstream engagement is not just a matter of timing but also of what issues are included on, or excluded from, the agenda. Experiences with novel technologies such as genetically modified organisms reveal that publics tend to address wider and more fundamental questions such as why use this technology at all, under what conditions, who is accountable, and who is in control 2000; Macnaghten, Kearnes, & Wynne, 2005). If technology is treated as a given, or if its beneficial role is assumed a priori, input from public deliberation is marginalized. In discussions where this happens, publics may be left unsatisfied because their fundamental concerns have not been addressed and are discarded as belonging either to an earlier stage that has already passed or to an imaginary later point in time where "more facts will be available" . The scientists or policy experts, for their part, may be left wondering why they have not received straightforward answers to their questions relevant to the present technical design stage. As a response to the Collingridge dilemma, a perspective of co-evolution of science, technology, and society-rather than a linear innovation modelhas been proposed , such as in constructive technology assessment . Technological objects are an intersection of material and social factors . Therefore, even in the development phase, where implicit assumptions about social uses of technology are made, the user plays a role . These approaches give precedence to the importance of sociotechnical issues in technological innovation. However, since the main focus is still on the technology in question, in most cases users are restricted to taking that technology as a central reference. What is lacking is an additional perspective in which everyday-life issues that are not necessarily related to technology, but nonetheless influence its reception, can come to the foreground . In this article, we show by means of a study of designeruser interaction that despite the technology orientation in public engagement exercises, other issues that are not allowed onto the agenda are still at play, even if they are not made explicit. This shows the importance of how the topic agenda is managed. Even if the timing of engagement meetings is right, there is still the question of which themes gain access to the discussion and which are excluded a priori or receive only marginal attention . Experts tend to focus on "hard" impacts such as health, environment, and safety, whereas publics raise issues concerning political, cultural, and moral, or "soft," impacts. Soft values tend not to be taken into account because they are treated as private and harmless . Topic agendas of engagement meetings are inextricably bound up with the timing, such as when users question issues for which, from the innovators' point of view, the stage in which these can be addressed has already passed . The implication is that often, when innovators do involve users, they pose issues that should have been addressed at an earlier stage-the stage at which from the innovators' perspective there was too little concrete information available and too many uncertainties to substantiate nonexpert involvement . The next issue in public engagement concerns the quality of the interaction itself and how it is connected to policy implications. The fact that a dialogue between innovators and prospective users takes place does not mean that there is any "real" participation of other than expert stakeholders in the innovation process . Even if "lay views" on proposed innovations are invited, in public debates scientific expertise may still trump experiential expertise , and participatory language may coexist alongside deficit framings of the public . In addition, the unfamiliarity and newness of the interactional setting of these kinds of events may cause uncertainty for the participants about what kinds of interactional genres to draw on, as well as for the analysts about how to interpret the interaction that takes place . A lack of attention to the discursive processes at play and interpreting the discussions in terms of recommendations and outputs may therefore cause the real value of these meetings to be missed . It has been noted that instrumental approaches such as evaluation questionnaires miss the extent to which the positions, values, outcomes, decisions, and so on are constructed during the moment-to-moment negotiations that take place during these events . While there is some concern in the literature with actual interactions within engagement exercises, the focus is still primarily on the content of these discussions, or on participants' contributions to the interaction from an individual-cognitive perspective. In an analysis of innovator-prospective user interaction, we show how participants' relationships are embodied in and shaped by more structural features of the interaction, such as questionanswer sequences. The innovators' questions, for example, through their yes/no format and built-in preferences and presuppositions, make specific kinds of responses relevant. While question formats may be resisted, such resistance is accountable. These systematic-but for participants not directly available-features of the interaction may explain why some of the problems between innovators and users are persistent but hard to pin down. In our analysis of discussions between innovators and patients 1 about emerging medical technologies, we find that the three problems mentionedtechnology orientation, the restricted topic agenda, and the quality of the 464 Science Communication 34 interaction-are related. The questions raised by innovators in these meetings, which convey, among other things, a technology-orientation, establish a limited agenda, and this is a barrier to fruitful dialogue. As we will see, what participants make relevant from the questions as being restrictive is not only assumptions about what problems they have but also, and perhaps predominantly, the fact that problems are assumed. We show that the success of upstream engagement is not just a matter of when to involve the end user in the design process but also of the kinds of answers the innovators make others, and themselves, accountable for during the discussion. This happens irrespective of what participants reported as their best intentions and the seemingly well-timed and open nature of the event. --- Discursive Psychology We examine this dialogue from a discursive psychological perspective , a form of discourse analysis that analyzes talk with regard to social actions being performed, and identifies obstacles to interaction between innovators and prospective users in engagement exercises. This requires detailed examination of the social actions performed in interactions between participants. The questions raised, and the answers given, are not so much reflections of participants' mental states as ways in which participants manage social relations between speakers regarding what each party knows, can know, or is responsible for knowing. These social actions are indicative and formative of the innovation process and the relationship between innovators and patients. The discursive psychological approach, developed in the 1990s by Derek Edwards and Jonathan Potter , focuses on the analysis of text and talk as social practice. It draws on the tradition of conversation analysis in its close empirical investigation of the details of interaction and in its particular focus on what people do with their talk rather than what their talk reflects. This discursive approach is fundamentally different from a cognitive view where what people say is treated as a window to their cognitions, emotions, and attitudes. Reference to being tired or upset, for example, can be used to avoid responsibility for a particular action. A neutral description can be used to build credibility of one's claims, a bad memory to account for forgotten actions. --- Veen et al. --- 465 Although discursive psychology has rarely been applied as a technology assessment tool, there are a few exceptions. For example, a study of people's talk about notions of health and risk that are central to nutrigenomics highlights the tension between the assumption that people will simply avoid unhealthy eating habits when informed about the health risks and the remarkable finding that people account for healthy behavior in their everyday interactions . In another study, analyses of celiac disease patients' interactions with other patients, family members, and experts are used to gain insight into patients' everyday-life practices on which innovations of Celiac Disease Consortium research will have an impact, with the aim of incorporating patients' concerns and wishes into the development trial . Discursive psychology highlights the constructed and rhetorical nature of accounts. Saying that talk has a rhetorical dimension means that the selection of one particular description over others resists potential alternative versions. For instance, "I'm a man" undermines being a woman, and this could in certain situations be treated as a defense. Another distinguishing aspect of discursive psychology is that it examines these descriptions as part of the sequence in which they are embedded, and on the basis of which participants make sense of what is being said at a particular moment in the interaction, rather than looking at isolated sentences. Therefore, the development of the interaction before and after these sentences always has to be part of the analysis. This perspective has consequences for understanding users' reactions to emergent technologies because, first of all, its focus on discursive action allows for a better understanding of users' reactions to technology on their own terms, and second, it takes into account the role of the expert and moderator as part of the interactional context ). The findings of analyses can reveal blind spots about the interaction between users and innovators that can be used as a basis for improving and adjusting the process of co-creation of technologies . --- Question Design Specifically, we focus on the kind of questions that the innovators pose to patients and how patients respond to these. Question design mirrors human 466 Science Communication 34 relations and is an index of the social relations between speakers and recipients . Question design has been a topic of conversation analysis, which has studied question design in many different contexts such as news interviews, health visitor interactions, and physicians' history taking . Heritage identifies three unavoidable features of questions: they set topic agendas and action agendas for the response, they embody presuppositions, and they incorporate preferences concerning possible answers. In relation to the first feature, insofar as questions can be designed to exert control over the terms of the responses, they establish topic and action agendas . For example, the question "what's for dinner?" establishes a topic agenda that makes relevant answers concerning food and an action agenda in that the respondent is expected to provide a particular kind of response-that is, a menu. Questions construct which responses are relevant but also provide freedom. For example, yes/no-type interrogatives make relevant a response with the type-conforming tokens "yes" or "no," which may then further be qualified or elaborated on . Examining the question agendas of the innovators reveals what they construct as relevant knowledge or feedback from the patients, the "deficit" patients can fill, what they make patients accountable for knowing, and what not. On the other hand, it shows what the innovators make themselves accountable for and how they construct patients' roles or parts in the innovation process. The second feature of questions is that they always embody presuppositions-at the very least that the respondent is in a position to answer the question. In the previous example, there is the presupposition that the recipient has access to the information about, or can decide, what is for dinner. Examining these presuppositions provides insight into what is treated as given by innovators-which also precludes these givens from being "in question"-and how these presuppositions are treated by patients. These presuppositions can shape patients' responses , and patients can confirm or disconfirm them. The final feature of questions is that they incorporate preferences for certain types of responses. YNIs particularly incorporate preferences . In interactions between health professionals and patients, they have been shown to "severely limit the contributions that patients may make to the interaction" . --- Veen et al. --- 467 --- Data and Method Background to the Meetings Our case study is a series of meetings between CD patients and expertinnovators about emergent medical technologies in this field. CD, or gluten intolerance, is an autoimmune disorder of the small intestine. For CD patients, gluten intake can lead to a variety of symptoms such as digestive problems, malabsorption, growth retardation, osteoporosis, and chronic fatigue. Currently, the only available therapy is excluding gluten-containing foods from the diet completely. This lifelong gluten-free diet is a difficult prospect since gluten is found in wheat, barley, rye, and many other daily foods. Because most modern foods are processed, even products that appear safe to CD patients may have been contaminated with gluten from other sources . The CDC is a Dutch innovative genomics cluster consisting of representatives of scientific research, patient associations, social science, dieticians, general practitioners, and industry. The goals of the CDC are the development of improved diagnostic procedures, novel therapeutics, and safer foods for CD patients. Since the research of the CDC is likely to drastically affect patients' lives, a clear understanding of the attitude of patients toward research developments is needed to guide and implement the CDC's work . As part of this aim, the CDC engaged in dialogue with patients about recent research developments. In 2008, the CDC organized a series of information meetings between patients and CD expert-innovators to inform patients about current research developments and receive feedback on those developments. The topics they discussed were diagnosis and screening, gluten-safe wheat and oats, and a gluten-neutralizing pill. In this article, we examine how patients and experts discussed the latter topic of the gluten-neutralizing pill, because of both its possibly revolutionary potential and the controversy surrounding it. The possibility of the gluten-neutralizing pill is based on the discovery of an enzyme that can work in the stomach to degrade gluten peptides into very small fragments before reaching the small intestine and triggering the inflammatory autoimmune response of CD patients . The presence of this enzyme in the stomach of CD patients would therefore potentially allow them to eat food containing gluten without becoming ill. If this pill in fact worked for all types of food and for all patients, it would provide the first alternative therapy to the current practice of CD patients avoiding gluten altogether. It is still doubtful whether this scenario is in fact technically possible. The meetings took place while clinical trials were still being conducted, and at the time of writing the pill is still at the research stage. It is as yet unknown whether the enzyme will work equally well in a human stomach as in the laboratory, for how long it will work, and which types of food and what dose would be required. The implication is that, whereas innovators were in the first instance talking about something that could completely replace the diet, a more likely result for the near future is a pill that can be taken once in a while alongside the diet. This pill could be used in situations such as emergencies, on special occasions, or to alternate between gluten-free meals at home and a regular diet at work or in school. Innovators still expect that this would improve the quality of life for CD patients . The first reactions of the Dutch CD association to this development were mixed, because it would reduce patients' dietary compliance. Also, research shows that there is a group of patients that are satisfied with the diet and would not want to eat gluten-containing foods . Four meetings were held, to which members of the Dutch CD association were invited by the CDC. This was done by an invitation on the Nederlandse Coeliakie Vereniging website and in their magazine, which invited patients to a meeting in their area to come and hear about the latest developments in CD research, discuss with CD researchers, and give them feedback on these developments. On average, there were six patients per group, of whom 70% were female and 30% male. The age range was spread equally from young adults to older persons and education from high to low. At each meeting, two members of the CDC were present. To ensure the consistency of information offered to patients, the first was a member aware of all research developments and present at all the meetings. Although this member also acted as a moderator, we found that in practice he was mainly treated by patients as a CDC researcher. The other member, who varied from meeting to meeting, was a scientist with a particular expertise in topics such as the pill, genetics, or food genomics. In practice, both members were treated equally by patients and were asked and answered questions about all facets, from scientific details to design or insurance coverage. All the meetings followed the same general pattern. First, patients read the information sheet about the pill and listened to a short introduction by the expert-innovator. Then they asked clarifying or information-seeking questions about the pill and its developmental context. This meant that the innovators had to initiate the part of the meeting in which patients gave their feedback on Veen et al. --- 469 the pill. Since without exception this stage of the discussion was initiated by a question, we examined the way the question design framed the discussion and how, by doing this, a particular social relation between patients and innovators was implied. We were interested in this because, as had been seen in previous research , introducing an innovation always entails certain presuppositions, and the kind of response that it elicits depends, to a large extent, on these presuppositions. --- Data Collection and Analysis The meetings were audio recorded, which yielded approximately 7 hours of recordings. These recordings were transcribed to word-level accuracy by the first author of this article, and relevant passages were subsequently transcribed in more detail, including pauses, overlap, and speech errors . All transcripts were analyzed, and from this initial analysis, sections that stood out were selected to be transcribed and analyzed in more detail. Although because of space limitations we are only able to discuss a few fragments, the analysis presented in this article is based on a much larger corpus of data. The fragments were translated into English with the help of a native speaker. Since this activity of translation involves interpretation as well, it should be noted that the analysis was performed on the Dutch fragments, and the translated fragments aim to capture the literal meaning as well as the analysis as closely as possible. Using a discursive rather than a cognitive approach, we make no assumptions about the motivations or expectations of the participants, such as what their interest was in coming to the meeting. Rather than looking at the source or cause of the interaction that takes place, we examine whatever participants bring to the conversation themselves and the action this performs. If psychological categories such as intention or motivation do play a role, we examine how they are drawn on in the interaction to perform certain interactional business. In our analysis, we focus on how patients design their discourse to accomplish various social goals rather than only on the content of what they are saying. Instead of treating patients' talk as isolated evaluations of the pill, we analyze the talk as occasioned by its interactional environment, in this case the way in which the innovators construct accounts of the pill and design their requests for inviting patients' responses to it. Rather than working with preestablished hypotheses, discursive psychology aims to develop explanations for patterns found in the data and deviations from those patterns. The burden of proof is on the analysts who have to demonstrate their claims on the basis of participants' own understandings displayed in the data . The two main principles that guide the analysis are the sequential and rhetorical nature of talk. Sequential analysis means that rather than looking at isolated segments of talk, statements and accounts are examined for their function in their sequential context, for example, countering or supporting a previous speaker's claim. The rhetorical principle refers to hypothesizing what alternative or opposite version the speaker might have selected, as a way to gain insight into the interactional business performed by the current version . --- Analysis: Restricting the Engagement Agenda Through Question Design In this analytic section, we examine what is constructed by innovators as a relevant response for patients and how patients respond to this. We start at a moment in the discussion where there is a transition from innovators as providers of scientific information and answering questions about the pill to innovators who want to know from patients what they think about the pill. In all cases, the innovators initiate this part of the discussion by asking patients a question. In our analysis of the way innovators introduce the problem to patients, we find that their questions incorporate the presupposition that the pill is accepted by patients and that they confine the topic agenda to discussing possible uses of the pill. The questions also embody a strong preference for an affirmative answer. An example of this pattern is shown in the following extract that takes place after an elaborate answer to a patient's question about the pill. Here, it is one of the patients who observes a transition from information giving to requiring patients' input: The patient's turn establishes what patients "↓think of such a pill" as a new topic agenda, but "really" casts doubt on whether this is actually relevant for the experts. Although acknowledging the relevance of this question , after a preface the innovator-expert ends up asking a different set of questions that shift the topic focus to patients' use of the pill. This reformulation is achieved by a description of dietary practice as a burden . Furthermore, this description is presented as something the patients themselves have said . So the question the expert finally asks is accounted for as occasioned by the patients' own presentation of the diet as difficult. The action agenda is constructed in different ways in the question the patient proposes to answer and the one the expert actually asks. In the first, patients are invited to share their thoughts, and in the second, they are offered a choice of either affirming use of the pill or affirming that the innovators are developing something useless The question offered by the patient explicitly constructs the innovators as requiring information from the patients and asserts no knowledge concerning a likely answer. In the question the expert poses, this information gap is much smaller. It is 472 --- Science Communication 34 prefaced by a description of the situation of the addressees, implying that the questioner knows their situation as well as the possible reactions they might have to it. It is just a matter of knowing which one. This leaves much less room for epistemic maneuvering on the part of the respondent. There is a difference in the presuppositions set up by the patient's turn and the innovator's. Wanting to know "what patients think of such a pill" presupposes that patients have an assertable opinion about the pill but does not make any assertions about how to frame this opinion or what it means for the development of the pill. The expert, on the other hand, asks patients to assume in their answers that a particular pill is on its way. The preface to his question is set up as a first part of a contrast in which either the pill will be used by patients or it will have been a waste of time for its designers. In terms of action agendas, the patient's turn invites patients' responses in terms of asserting opinions, the innovator's turn in terms of making a choice. This invokes a fundamental difference in the relationship between patients and innovators. In the first case, patients are involved in terms of their thoughts and opinions about the innovation process in general; in the second case, in terms of choosing between available options that have already been decided. To see how the questions differ in terms of their preferences for a certain type of answer, consider possible responses to the question the patient offers to answer and the question the expert asks: 1. What do you think of such a pill? I think that . . . I like it, because . . . I don't like it, because . . . I would prefer a pill that . . . Et cetera 2. Will patients use it or are we just sitting around developing something that . . . Yes, we will use it. No, the pill is useless. The first question allows for any kind of answer that is constructed as an opinion about the pill. In the second case, there are two questions linked together. The first is a YNI, with a preference for an affirmative answer, given that in the question preface the diet is constructed as a problem for which the pill could offer a solution. This is enhanced by the second question in which the alternative to accepting the pill is constructed as an affirmation of the innovators having developed something useless. The YNI "will patients then ↑use it" is embedded between a preface that establishes a positive response as affirming the pill as a solution to an unpleasant situation and a postscript that frames a negative response as reducing the innovators' efforts to a waste of time. The preference is therefore clearly for a "yes" answer. The first response to the expert's question is constructed jokingly, followed by the patient's laughter and that of others, including the expert's. P4 displays reluctance to answer the question by not providing a typeconforming response. This reluctance can be seen as resisting the constraining character of the expert's question. The joke is, of course, that this patient gives a literal answer to the question "will patients use it," by taking it up as a request to make a prediction about the future of patients' behavior. By withholding an affirmative response to the expert's question, she also resists affirming what the expert constructs as being at stake in the question regarding use of the pill: "are we just sitting around" suggests that if the pill is not accepted, it is the innovators who will be negatively affected. The second response starts with a type-conforming "yes" but proceeds to qualify this affirmation by making the response to the question contingent on another factor: "it really depends on how you use it" . P2's description of a pill alongside the diet as "much harder" than the current situation challenges the presupposition in the expert's question that the pill would make things easier for patients. Her account is a departure from what was asked for-namely, whether patients would use the pill or not. Rather than taking the pill as a given, and evaluating it, P2 poses conditions on the kind of pill that she would want: "if there is something, then I would like to have something that . . ." . She treats the version of the pill that the expert is presenting as only one of more possibilities, thereby challenging the terms of the expert's question, in which the only choice is between affirming the option presented by the innovators and discarding it entirely. This pattern of a restricted topic agenda, presuppositions about patients' problematic dietary practice and the pill's safety, and a preference for affirming use of the pill was found in all the groups. In the following extract, a similar question design is used, in that it gives patients a choice of affirming or rejecting the particular use of the pill that the expert proposes. 14 P2 No but °for yes°A s in the previous extract, the innovator-expert asks the patients to assume in their answers that the pill is already available and sets a topic agenda in terms of discussing use of the pill . The question of the expert is a YNI, with a preference for an affirmative answer. This is enhanced by presenting the pill as unproblematic: available, safe, and works a hundred percent. It is important to note that in Line 3 the emphasis is on "ta:ke" rather than on "always." Casually including "always" in this way constructs it as obvious and avoids thematizing it as something to be considered in the response . This reinforces the notion that if they took it, it would be all the time. In addition to that, the question also constructs a specific way of using the pill: "always," "each day," eat "three meals a day," and "take a pill in advance thrice a day." As P2 makes explicit in Line 6, this formulation assumes that patients would want to eat gluten if they could. "Only if" qualifies the question, thereby exerting agency with respect to its terms. In Line 12, P1 provides a type-conforming but dispreferred answer to the expert's question. The answer is type conforming in the sense that "no" is an interactionally appropriate response to the YNI, but of the possible interactionally appropriate alternatives, it is the dispreferred answer. This is also shown by the fact that she gives an account for not wanting to always use the pill. In this account, eating gluten-free is dismissed as being a problem . So in both responses, the implication that the diet is a problem is dismissed. The assumption that if a pill were available patients would eat gluten with every meal disregards patients' already established dietary routine. A negative answer to the question of the pill may therefore be seen as not so much a negative evaluation of the pill itself but of the assumptions that the question introduces. In the following extract, this becomes clear as patients initially respond with agreement tokens while the expert is asking the question , until he adds the presupposition that patients would take the pill each day . This extract occurs after a discussion about different physical properties of the enzyme used in the pill in which it was established as safe and reliable. In Lines 1 to 9, the expert constructs a YNI, which just as in the previous extracts contains presuppositions about the use of the pill. The "just" constructs the emphasized "buy" as uncomplicated and self-evident. Note that agreement tokens are only uttered after a pause , during which an immediate answer remains absent, and an invitation to assume the pill's safety . In so doing, the patient participants display entitlement to only accept the pill in and on their own terms, if at all. They are responding with agreement until Line 10, where their talk no longer goes along with the question's preference structure. P1's "That" rejects the specific kind of use of the pill proposed in Line 9. In Lines 14 and 15, P2 subsequently problematizes the assumption that the problem for which the pill would be a solution is clear by further qualifying the response. --- Fragment 3 In all the meetings, the discussion about patients' potential use of the pill was opened by the innovators asking closed questions, mostly YNIs: 1. "Will patients then ↑use it or ehhh are we just sitting around here ehhh developing something . . ." --- 476 Science Communication 34 2. "Would you always want to ta:ke [the pill]?" 3. "Who would just stick to the diet?" 4. "Would you just ehhh buy it?" 5. "Would you take it each day?" At their most basic, these questions serve to elicit information that the innovators can use to inform technical and policy decisions regarding the development process. In order to do so, however, the innovators need to leave the familiar scientific domain and pry into the patients' everyday life. These questions presuppose the use of the pill and therefore ask patients to affirm or deny a specific use rather than allowing the more fundamental possibility of not using it at all or discussing reasons for using or not using it. By asking patients to imagine that the pill is already available, the question of whether a pill is desirable in itself is excluded from the topic agenda. The type of questions the experts ask are questions about how patients would use the pill. The prefaces to these questions contain presuppositions such as that the diet is hard, the pill is safe, patients want to eat gluten, or that they want to use the pill every day. Although use is treated as "in question," there is also a strong preference for "yes." The innovators' questions are formulated in such a way that patients are restricted to affirming or denying a particular way of using the pill. Interestingly, by establishing a restricted action agenda, the questions exclude giving substantive information. However, while the question design makes certain types of answers relevant, this agenda can be resisted. Earlier we saw that such resistance is accountable, as became visible in the delays in answering, the qualifications and softenings made, and accounts for not going along with the question's preference structure. But patients sometimes talked among each other without visibly orienting to the innovator-expert. When they were no longer placed in an immediate responsive position regarding the innovator's talk, their utterances contained no language that weakened the declarative claims that were made, thereby displaying primary rights to evaluate the matters assessed , namely, their everyday lives . The following extract occurs after a discussion about the expected price of the pill, in which P1 makes a case for making the pill affordable by providing insurance coverage for it . --- Fragment 4 Group 3, 10.53-12.46 1 P1 And we will have to join together and take an uh. stand to 2 make them understand somehow uhhh that we need↑ that. P1's description of patients being unjustly burdened by the diet in terms of time and money is used as an account that patients "need" the pill and thereby establishes patients as having the right to make demands about its price. This marks a shift from producing a response to the expert's question of how patients would want to use the pill to a position where patients are the initiating party. Rather than something offered to them that they can then take or leave, describing patients as unjustly burdened constructs the pill as something that is demanded by patients and something about which they have the right to make demands on, on account of their direct access to their everyday life. P1's description is therefore used to reject the identity of a passive, receiving party of medical innovation. "On the other hand" signals a confrontational stance on the part of P5 with respect to the previous turn. By constructing the diet as not complicated and rejecting P1's claim that patients "need" a pill, P5 resists the construction of CD as an encumbering external circumstance beyond patients' control. Instead, characterizing the diet as a problem is made contingent on the patients' agency: "there are a lot of things that you can eat" . --- 478 --- Science Communication 34 Although there is apparent disagreement, P1's turn performs a similar action as P5 with respect to the innovators' presentation of the pill: Using a description of everyday life, both reject being a passive recipient of something that the innovators offer. P1 accomplishes this by establishing patients as having the right to make conditions about the pill. P5 does so by reflexively constructing the pill as redundant. The expert's questions, where the pill is taken as the starting point and the problem for which it is a solution is presupposed, are successfully reformulated into taking everyday social situations as the starting point and from there constructing the kind of solution the pill would be or not. Note, however, that there is no visible uptake of this kind of talk by the innovators. It seems as if the question-answer sequences that start the discussion remain separate from these spates of talk that display a lively debate among patients themselves, without the innovator-experts being involved in or oriented to it. --- Discussion and Conclusion In this article, we looked at a set of innovator-user meetings regarding an emerging medical technology: the gluten-neutralizing pill. The analysis shows how the question design that the innovators draw on contains presuppositions regarding the patients' problematic life, the pill's desirability, and its safety and constrains the topical agenda to use of the pill. In addition, the questions show a built-in preference for affirmation of the pill's use, thereby also inviting the acceptance of the presuppositions made in the preface. Patients, on the other hand, raise concerns that do not fit the question format and, for example, call the benefit of the pill itself into question. Irrespective of the official aim of the meetings , participants negotiated their epistemic territories, including who is informing whom, thereby constructing and reconstructing the nature of the event. Patients defined themselves as free deliverers of opinions, where the innovators' questions suggested a fixed choice between unequal alternatives . What seems to be at stake here is not merely the content of the presuppositions made but also that by making them, innovators claim direct access to the patients' everyday life-thereby failing to treat the patients as having privileged access to their own experiences and having specific rights to narrate them. By resisting the question format and/or dealing with its assumptions one by one, patients claimed epistemic ownership. When no longer in the vicinity of the innovator's questions , patients were not only allowed "first-position" statements , but they also constructed their position as such, demanding innovators to be responsive, not vice versa. However, there seemed to be little uptake of this talk by the innovators. Questions position participants and involve choices "regarding what each party knows, can know, or is responsible for knowing" . Certain kinds of answers are made relevant, others made accountable, and thus a powerful basis for relating to each other is created. This, of course, can be countered and resisted, but such resistance is accountable, meaning that it takes more interactional effort on the part of participants to address issues that do not align with the agendas set by the initial question. Our discursive approach shows that without having to resort to constructs such as expectations, intentions, motivations, or other cognitive phenomena, structural features of the interaction such as question design and response can be analyzed as to how they reflect and build social relationships. Question design indexes these relationships "regardless of the specific aims of the question" . Even in the case of "ostensibly silly questions" , for instance, participants are accountable for not going along with the question's design and framing. Interestingly, the ways in which the questions structure the discussion and make resistance accountable are not made explicit by any of the participants in the discussion, including the moderator. We may speculate that one of the reasons why these issues remain under the table is that for both the CD experts and the patients, the engagement meetings are an unfamiliar setting, and there are no protocols or scripts for how they should behave . A more encompassing reason, however, is that social relationships, no matter how abstract, manifest themselves in a systematic but subtle way without necessarily involving conscious acts. This may explain why a pattern such as the technology orientation in the experts' question design can be so persistent and hard to reflect on: While it does play out in the interaction, it may not be instantly visible to participants themselves. Recent literature has described how users often raise upstream concerns at a downstream stage . In this respect, Garud and Ahlstrom's distinction between insiders and outsiders is relevant. Insiders to the technology process are described as having the end product in mind and perceiving the outside world-including public acceptability-as barriers to be overcome. Outsiders, on the other hand, are described as "ranking technologies on a common set of criteria [that] provides outsiders with a means to exercise control over insiders' processes" . Our study shows how insider and outsider perspectives and their mutual frictions are also embodied in the 480 Science Communication 34 interaction such as in question-answer sequences, perhaps most clearly in the struggle about who is the rightful owner of the users' lifeworld-a lifeworld on the basis of which, for example, a problem can be formulated that requires a technological fix. Despite efforts to limit the discussion to how the proposed innovation will or will not be used, patients continued to address the question of why use it at all. This is not just a matter of badly timed meetings; rather, the timing may be different for different parties. The way the innovators formulate their questions and respond to patients implies that the proposed innovation will come in any case, and it is just a matter of adjusting it to patients' wishes. Patients, however, address issues such as what exactly the problem is for which the pill could potentially offer a solution and whether there is such a problem. We argue that unresolved matters will continue to be addressed by patients, even at later stages of the innovation trial. From the innovators' perspective, the meetings we examined did take place at an early stage, since it was right after the first concrete research finding-the discovery that an enzyme already used in other products could also be applied to neutralize gluten in patients' stomachs. However, it may be worthwhile to meet with patients still earlier. Questions such as what patients consider an improvement of their situation and what kind of conditions would have to be met to be considered such an improvement could be addressed in a much earlier stage, thus allowing the pill to be designed and formulated as a response to issues raised by patients. Granting them their "first position" and the corresponding primary rights to evaluate seems crucial here. The orientation of the talk may be as important here as the actual timing of the process and patients' space for influence. Question-answer sequences, for example, communicate relationships irrespective of the alleged intentions of the people in it. In contrast to what the innovators' questions conveyed about the nature of the event, patients oriented to it in terms of a process of exploration, of discussing different constructions of CD and the corresponding desired innovations. Rather than providing a clear-cut answer to the questions, they were negotiating the terms on the basis of which of these questions could be addressed at all. This means that considering patients' isolated statements about the pill as representative of their lifeworld would completely misjudge the character of the discussion. A discussion on how to use the proposed innovation in daily life requires patients to also address more fundamental questions of identity, agency, and responsibility . This explorative process is reinforced by the fact that participants in focus groups often use these meetings as a way to explore different options-that is, arguing aloud rather than stating ready-made opinions, thereby orienting to the identity of a focus group ). --- Veen et al. 481 While our study inevitably has a limited focus, the analysis shows that the specific content of what people say should be understood as embedded in particular interactional structures. One way of making such features available for reflection is by using the so-called discursive action method . This is a discourse-based method that aims to turn participants into analysts of their own discourse. The method enables participants to reflect not only on what they say but also on the effects, consciously or not, of saying certain things, in certain ways, at certain momentsfor example, what their questions convey irrespective of any intentions. Co-construction of technology is a creative activity that can-and should-be done purposefully, at least for an important part. Discursive psychology can be used as a tool to aid this process, promoting mutual understanding of parties from different backgrounds by providing insight into each other's social actions. The results of these analyses can be used as a basis for improvement and furthering of the aim of involving those whose lives innovations are likely to affect. --- Appendix Transcription Notations P1, P2, and so on are patients, Ex is the expert. Based on Jeffersonian transcription . [text] Overlapping speech (x. --- Declaration of Conflicting Interests The authors declared no potential conflicts of interests with respect to the research, authorship, and/or publication of this article. --- Note 1. We talk about patients and innovators/innovator/experts as to indicate on what basis the participants officially entered the engagement meetings. However, our analysis does not start from these fixed categories but looks at how identities and their corresponding characteristics are formulated and reformulated to achieve different goals. --- Bios

This article examines discussions between innovators and patient users about emergent medical technologies in the field of celiac disease. Using discursive psychology and conversation analysis, the authors analyze participants' talk with regard to the social activities performed. They find that the topical agenda, preference structure, and presuppositions incorporated in the innovators' questions restrict patients' scope for saying things in and on their own terms. Not participants' intentions per se but what the questions indirectly communicate profoundly shapes the agenda of these meetings. This may explain why some of the difficulties of innovator-user interaction are persistent and hard to pinpoint.

Introduction Today, equality and inclusion are widely recognized as fundamental principles that should be extended to all individuals, regardless of their abilities or disabilities. However, for individuals with mobility limitations, achieving true equality and inclusion remains a significant challenge. Wheelchair accessibility plays a crucial role in bridging this gap and ensuring that individuals with mobility impairments can fully participate in various aspects of life. Wheelchair accessibility refers to the provision of physical and social environments that enable wheelchair users to navigate and participate in society on an equal basis with others. It encompasses various aspects, including accessible public spaces, transportation systems, educational institutions, workplaces, and recreational facilities [1]. Wheelchair accessibility is not merely a matter of physical infrastructure; it encompasses attitudes, policies, and inclusive practices that promote social integration and equal opportunities for wheelchair users. The problem arises when there is a lack of comprehensive wheelchair accessibility, resulting in barriers that hinder full and meaningful participation for individuals with mobility limitations. These barriers can be physical, such as inaccessible buildings or transportation systems, or attitudinal, such as societal stigmatization and discrimination. Limited accessibility not only restricts mobility but also hampers independence, social engagement, education, employment, and overall quality of life for wheelchair users [2]. The significance of wheelchair accessibility goes beyond individual experiences. It is a matter of human rights and social justice. The United Nations Convention on the Rights of Persons with Disabilities explicitly recognizes the rights of persons with disabilities, including the right to accessibility [3]. Access to proper mobility aids, including wheelchairs, is essential for individuals to exercise their rights and live with dignity. The purpose of this research is to explore the importance of wheelchair accessibility in bridging the gap to equality and inclusion. By examining the barriers faced by wheelchair users and the impact of limited accessibility on their lives, this study aims to shed light on the urgent need for comprehensive wheelchair accessibility measures. Moreover, the research will investigate successful case studies and best practices in wheelchair accessibility implementation to identify strategies that can promote equality and inclusion. The findings will serve as a foundation for policymakers, urban planners, architects, disability rights advocates, and other stakeholders to develop inclusive strategies, policies, and practices that bridge the gap to equality and inclusion for wheelchair users. Wheelchair accessibility is an essential component of achieving equality and inclusion for individuals with mobility limitations. By addressing the barriers that hinder full participation and promoting comprehensive accessibility measures, we can create a society that values and embraces diversity, ensuring that wheelchair users have equal opportunities and can fully contribute to their communities. --- Significance of the proposed Study The significance of wheelchair accessibility cannot be overstated, as it plays a pivotal role in promoting equality, inclusion, and overall well-being for individuals with mobility limitations. The following are key aspects highlighting the significance of wheelchair accessibility: • Independence and Autonomy: Wheelchair accessibility enables individuals with mobility impairments to navigate their environments independently. It empowers them to engage in activities of daily living, access public spaces, and participate in social interactions without relying on others for assistance [4]. By promoting independence, wheelchair accessibility enhances individuals' self-esteem, self-confidence, and overall sense of control over their lives. • Social Participation and Inclusion: Wheelchair accessibility is essential for facilitating social participation and fostering inclusion. Accessible environments ensure that wheelchair users can actively engage in community activities, educational pursuits, employment opportunities, and recreational events. By removing physical and attitudinal barriers, wheelchair accessibility enables individuals to interact with others, form social connections, and contributes to society, thus combating social isolation and promoting a sense of belonging [5]. • Education and Employment: Wheelchair accessibility in educational institutions and workplaces is crucial for ensuring equal access to education and employment opportunities. Accessible classrooms, lecture halls, and workspaces enable wheelchair users to fully participate in educational and professional settings [6]. This accessibility paves the way for individuals with mobility impairments to pursue higher education, acquire skills, and achieve their career goals, thereby reducing disparities and promoting inclusivity in academic and professional domains. • Health and Well-being: Wheelchair accessibility plays a vital role in promoting the physical and mental well-being of wheelchair users. Accessible environments encourage physical activity, mobility, and engagement in recreational pursuits, contributing to improved cardiovascular health, muscle strength, and overall fitness [7]. Furthermore, by facilitating access to healthcare facilities, wheelchair accessibility ensures that individuals can receive timely medical care and support, leading to better health outcomes and an enhanced quality of life. • Legal and Human Rights: Wheelchair accessibility is not merely a matter of convenience but also a matter of human rights. It is grounded in the principles of equality, dignity, and nondiscrimination. The UNCRPD recognizes the right of persons with disabilities to accessibility and mandates the provision of reasonable accommodations, including wheelchair accessibility. By ensuring wheelchair accessibility, societies uphold the rights and dignity of individuals with mobility limitations, promoting a more just and inclusive society [8]. Wheelchair accessibility is of utmost significance as it empowers individuals with mobility impairments, promotes social integration, provides equal opportunities, and enhances overall wellbeing. By removing physical and attitudinal barriers, wheelchair accessibility enables individuals to live independent lives, actively participate in society, access education and employment, and enjoy their fundamental human rights. It is crucial for policymakers, communities, and stakeholders to prioritize and invest in comprehensive wheelchair accessibility measures to create inclusive environments that foster equality and dignity for all. --- Importance of wheelchair accessibility Wheelchair accessibility plays a crucial role in achieving equality and inclusion for individuals with mobility limitations. Here are some key points highlighting the importance of wheelchair accessibility in this context: • Equal Opportunities: Wheelchair accessibility ensures that individuals with mobility impairments have equal opportunities to access and participate in various aspects of life. It eliminates physical barriers that may hinder their ability to navigate public spaces, transportation systems, educational institutions, workplaces, and recreational facilities [9]. By providing equal access, wheelchair accessibility creates a level playing field and allows individuals to fully engage in activities alongside their peers. • Independence and Empowerment: Wheelchair accessibility empowers individuals with mobility limitations to be more independent in their daily lives. It enables them to move freely, access facilities, and perform tasks without constant assistance [10]. This independence fosters a sense of autonomy, self-reliance, and control over their own lives, enhancing their overall well-being and quality of life. • Economic Participation: Wheelchair accessibility is instrumental in facilitating economic participation for individuals with mobility limitations. Accessible workplaces and business environments enable wheelchair users to seek employment, start businesses, and contribute to the economy [11]. By providing equal access to economic opportunities, wheelchair accessibility reduces disparities and promotes financial independence and selfsufficiency. • Civic Engagement and Political Participation: Wheelchair accessibility ensures that individuals with mobility impairments can actively engage in civic and political activities. Accessible polling stations, government buildings, and community centers enable wheelchair users to exercise their right to vote, attend public meetings, and participate in political campaigns [12]. This inclusion empowers individuals to have a voice in decisionmaking processes, fostering democratic values and promoting inclusive governance. • Family and Social Relationships: Wheelchair accessibility plays a crucial role in strengthening family and social relationships. Accessible homes and public spaces enable wheelchair users to fully participate in family gatherings, social events, and celebrations. By removing physical barriers, wheelchair accessibility promotes inclusive family dynamics and strengthens social connections, ensuring that individuals with mobility limitations can fully engage and enjoy meaningful relationships with their loved ones [13]. • Cultural and Recreational Opportunities: Wheelchair accessibility is essential for individuals with mobility limitations to access cultural and recreational opportunities. Accessible theaters, museums, parks, and sports facilities enable wheelchair users to engage in cultural experiences, entertainment, and leisure activities. By ensuring equal access to these experiences, wheelchair accessibility promotes cultural diversity, creativity, and the enjoyment of life's enriching pursuits [14]. • Aging and Long-term Disability: Wheelchair accessibility becomes increasingly important as individuals age or acquire long-term disabilities. As mobility needs change over time, accessible environments and assistive devices, including wheelchairs, play a critical role in maintaining independence, social connections, and overall well-being. Wheelchair accessibility allows individuals to age in place, actively participate in their communities, and continue enjoying a high quality of life [15]. • Positive Societal Impacts: Wheelchair accessibility benefits society. When individuals with mobility limitations are included and have equal opportunities, society benefits from their diverse perspectives, skills, and contributions. Additionally, accessible environments are more welcoming for all individuals, including parents with strollers, seniors with walkers, and temporarily injured individuals [16]. Wheelchair accessibility fosters a sense of compassion, empathy, and social responsibility among the wider population. Wheelchair accessibility is of paramount importance in achieving equality and inclusion for individuals with mobility limitations. It promotes economic participation, civic engagement, and cultural experiences. It strengthens family and social relationships, enhances well-being, and supports individuals as they age or acquire long-term disabilities. Moreover, wheelchair accessibility benefits society by fostering diversity, empathy, and equal opportunities. By recognizing the significance of wheelchair accessibility, we can build more inclusive communities that embrace the rights and dignity of individuals with mobility limitations. --- Objective of the proposed study The objective of this research paper on wheelchair accessibility is to examine the importance of wheelchair accessibility in bridging the gap between equality and inclusion for individuals with mobility limitations. The paper aims to achieve the following specific objectives: • To explore the barriers and challenges faced by wheelchair users in various environments, including public spaces, transportation systems, educational institutions, workplaces, and recreational facilities. • To investigate the impact of limited wheelchair accessibility on the overall well-being, social participation, and quality of life of individuals with mobility impairments. • To highlight the benefits and potential outcomes of improved wheelchair accessibility, such as increased opportunities for education, employment, independence, and social engagement. • To analyze existing policies, guidelines, and best practices related to wheelchair accessibility and identify gaps or areas for improvement. • To provide recommendations for proactive measures, including policy reforms, infrastructure modifications, awareness campaigns, and collaboration among stakeholders, to enhance wheelchair accessibility and create more inclusive environments. By addressing these objectives, this research paper seeks to contribute to the existing knowledge and understanding of wheelchair accessibility as a crucial component in achieving equality and inclusion for individuals with mobility limitations. It aims to inform policymakers, urban planners, architects, disability rights advocates, and other stakeholders about the significance of wheelchair accessibility and the actions needed to ensure a more equitable and inclusive society. --- Literature Review Wheelchair accessibility is a topic of great significance in promoting equality and inclusion for individuals with mobility limitations. This literature review provides an overview of key studies and scholarly works that have examined various aspects of wheelchair accessibility and its impact on the lives of individuals with mobility impairments. Numerous studies have highlighted the barriers faced by wheelchair users in accessing different environments. In their research, Taniguchi et al. emphasized the physical barriers, such as inaccessible buildings, sidewalks, and transportation systems that limit wheelchair users' mobility and participation [17]. They also identified attitudinal barriers, including negative stereotypes and social stigma, which can impede social integration. Research has demonstrated the significant impact of wheelchair accessibility on the overall quality of life of individuals with mobility limitations. For example, a study by Lee et al. found that wheelchair accessibility positively influences the social participation, psychological well-being, and life satisfaction of wheelchair users [18]. The authors emphasized that increased accessibility leads to greater independence and a sense of control over one's own life. Wheelchair accessibility in educational institutions and workplaces is crucial for ensuring equal opportunities. In their study, Braun and Naami highlighted that accessible educational environments and inclusive teaching practices are essential for students with mobility impairments to fully engage in learning [19]. Additionally, research by Butterworth and Hargrove emphasized that wheelchair accessibility in workplaces is critical for individuals with mobility limitations to access employment opportunities and contribute effectively in their chosen professions. Various studies have examined the role of policy and legislation in promoting wheelchair accessibility. For instance, Levine and Karner analyzed the impact of the Americans with Disabilities Act in the United States and found that it has significantly improved wheelchair accessibility in public spaces and transportation systems [20]. They emphasized the need for strong legal frameworks and enforcement mechanisms to ensure compliance and continued progress. Several studies have explored successful case studies and best practices in wheelchair accessibility implementation. For example, a study by Ghanem and Edirisinghe examined the experience of the city of Melbourne, Australia, in creating an accessible urban environment [21]. The authors identified key strategies, such as comprehensive accessibility audits, active community engagement, and ongoing monitoring, as crucial factors in achieving successful wheelchair accessibility outcomes. --- Examination of barriers and challenges faced by wheelchair users This literature review provides an overview of studies that have examined the barriers and challenges faced by wheelchair users in various environments, shedding light on the experiences of individuals with mobility limitations. Physical barriers significantly impede wheelchair users' mobility and access to different spaces. In their research, Smith et al. highlighted the challenges posed by inaccessible buildings, sidewalks, and transportation systems [22]. They emphasized the need for infrastructure modifications, including ramps, elevators, and curb cuts, to enhance wheelchair accessibility. Attitudinal barriers, including negative stereotypes and social stigma, pose significant challenges to wheelchair users' social integration. A study by Jarus et al. emphasized the importance of addressing attitudinal barriers through education, awareness campaigns, and promoting positive attitudes towards disability [23]. Wheelchair users often face social and emotional challenges due to their mobility limitations. Research by Sahoo et al. explored the experiences of wheelchair users and found that they frequently encounter social exclusion, limited participation in social activities, and feelings of isolation [24]. The study highlighted the importance of inclusive social environments and supportive networks. Public spaces can present numerous barriers for wheelchair users. A study by Jaidi and Pitt examined the challenges faced by wheelchair users in accessing and navigating public spaces, such as parks, recreational areas, and cultural venues [25]. The research emphasized the need for universal design principles and the removal of physical barriers to ensure inclusive environments. Transportation is a critical aspect of wheelchair users' daily lives, and barriers in this domain significantly impact their mobility and independence. Research by Liu et al. explored the challenges faced by wheelchair users in public transportation systems, including difficulties in boarding buses, inadequate accessibility features, and inconsistent enforcement of accessibility regulations [26]. Wheelchair users often encounter barriers in accessing employment opportunities and navigating workplace environments. A study by Sahoo and Choudhury examined the experiences of wheelchair users in the workplace and identified challenges related to physical accessibility, lack of accommodation, and negative perceptions from employers and colleagues [27]. The study emphasized the need for inclusive employment practices and awareness training. Wheelchair users often face barriers in accessing healthcare services and facilities. Research by Kamran et al. highlighted challenges such as inaccessible healthcare facilities, limited availability of medical equipment, and inadequate training of healthcare professionals in addressing the specific needs of wheelchair users [28]. The study emphasized the importance of improving healthcare accessibility and providing comprehensive, patient-centered care. Accessibility in educational settings is crucial for wheelchair users to fully participate in academic activities. A study by Salvatore and Wolbring explored the barriers faced by wheelchair users in higher education and identified challenges related to inaccessible classrooms, limited availability of assistive technologies, and social exclusion [29]. The research emphasized the need for inclusive educational policies and practices to ensure equal educational opportunities for wheelchair users. The barriers and challenges faced by wheelchair users can have a significant psychological and emotional impact. Research by Qaio et al. highlighted the psychological stress, depression, and anxiety experienced by wheelchair users due to societal barriers and limited accessibility [30]. The study emphasized the importance of providing psychological support and promoting resilience among wheelchair users. Wheelchair users who belong to marginalized groups may face intersecting barriers and challenges. A study by Sahoo and Goswami explored the experiences of wheelchair users from diverse backgrounds and identified additional challenges related to racism, discrimination, and socio-economic disparities [31]. The research highlighted the importance of recognizing and addressing the intersecting forms of oppression faced by wheelchair users. Advancements in technology and assistive devices play a vital role in addressing barriers faced by wheelchair users. Fuentes explored the use of technology, such as smart wheelchairs and mobile applications, to enhance mobility and accessibility for wheelchair users. The study emphasized the potential of technology in improving independence and overcoming physical barriers [32]. Empowerment and advocacy efforts by wheelchair users and disability rights organizations have been instrumental in raising awareness and addressing barriers. Research by Sahoo and Choudhury explored the role of self-advocacy and empowerment in improving wheelchair accessibility [33]. The study highlighted the importance of supporting self-advocacy initiatives and fostering the active participation of wheelchair users in decision-making processes. These additional points further contribute to the literature review, showcasing the multifaceted barriers and challenges faced by wheelchair users in various domains. The studies highlight the need for improved healthcare access, inclusive educational settings, attention to psychological well-being, recognition of intersectional challenges, advancements in technology, and empowerment through advocacy. Understanding these barriers is crucial for developing effective strategies and policies to enhance wheelchair accessibility and promote equality and inclusion for individuals with mobility limitations. --- Research gap and Novelty of the proposed study Despite the extensive research on wheelchair accessibility, there are still several research gaps and areas that warrant further investigation. This section discusses the research gap and novelty in the context of wheelchair accessibility and its role in bridging the gap to equality and inclusion. Research Gap: i. In-depth Examination of Cultural and Social Factors: While existing research has explored physical and attitudinal barriers, there is a need for more in-depth analysis of the cultural and social factors that contribute to wheelchair accessibility challenges. Understanding the cultural perceptions, social norms, and societal attitudes towards wheelchair users can provide valuable insights into the unique barriers they face in different communities and contexts. ii. Intersectionality and Multiple Marginalization: Limited research has focused on the intersectional experiences of wheelchair users who belong to marginalized groups. There is a need to explore the compounded effects of disability, race, gender, socio-economic status, and other intersecting identities on wheelchair accessibility and the challenges faced by individuals with multiple marginalization. iii. Long-term Impact and Health Outcomes: Further investigation is required to understand the long-term impact of wheelchair accessibility on the health outcomes and overall well-being of individuals with mobility limitations. This includes assessing the effects of accessibility on physical health, mental health, social participation, and overall quality of life. Novelty: i. Technological Innovations: The integration of technology and assistive devices has the potential to revolutionize wheelchair accessibility. Investigating novel technological solutions, such as robotic assistance, advanced mobility devices, and smart environments, can provide innovative approaches to address barriers and enhance accessibility for wheelchair users. ii. Empowerment and Advocacy: Examining the empowerment and advocacy efforts of wheelchair users and disability rights organizations can shed light on effective strategies for promoting accessibility and driving social change. Understanding the role of self-advocacy, community engagement, and collaboration can contribute to the development of empowering approaches to address accessibility challenges. By addressing these research gaps and focusing on the novel aspects mentioned, future research can contribute to a deeper understanding of wheelchair accessibility, its impact on equality and inclusion, and the development of innovative solutions that bridge the existing gaps. --- Technological Innovation for wheelchair accessibility Technological innovation plays a crucial role in enhancing wheelchair accessibility and overcoming barriers faced by wheelchair users. It offers novel solutions that can significantly improve mobility, independence, and overall quality of life for individuals with mobility limitations. Here are some key areas of technological innovation in wheelchair accessibility: --- Powered Wheelchairs and Mobility Devices Technological advancements have led to the development of powered wheelchairs and mobility devices with enhanced features and functionalities. These devices can be customized to meet individual needs and offer improved maneuverability, control, and comfort. Powered wheelchairs often incorporate advanced control systems, such as joystick controls, sip-and-puff controls, or head-controlled systems, allowing users with varying levels of mobility to operate the wheelchair effectively [34]. Here are some key points to understand in detail: • Enhanced Maneuverability and Control: Powered wheelchairs are equipped with electric motors and advanced control systems that allow for precise maneuverability. Users can control the wheelchair's movement using a joystick, touchpad, or other input devices. The motors provide the necessary power to navigate various terrains, including uneven surfaces, ramps, and slopes, offering increased freedom of movement. • Customization for Individual Needs: One of the significant advantages of powered wheelchairs is their ability to be customized to meet the specific needs of users. They can be adjusted to accommodate different body sizes, seating positions, and postural requirements. Customizations may include adjustable seating height, backrest angle, and footrest position, ensuring optimal comfort and support for the user. • Versatility in Indoor and Outdoor Environments: Powered wheelchairs are designed to provide seamless transitions between indoor and outdoor environments. They offer maneuverability in confined spaces like homes, offices, and shopping centers, as well as enhanced stability and control when navigating outdoor environments such as sidewalks and parks. Some models feature suspension systems to absorb shocks and vibrations, ensuring a smoother and more comfortable ride. • Power and Range: Powered wheelchairs are equipped with rechargeable batteries that provide the necessary power for operation. The battery capacity determines the range or distance that the wheelchair can travel on a single charge. Modern advancements have significantly increased battery efficiency, allowing users to cover longer distances without worrying about frequent recharging. • Advanced Seating and Positioning Options: Powered wheelchairs often incorporate advanced seating and positioning options to enhance user comfort and support. These may include adjustable seat widths, backrest angles, and seat tilt-in-space features. Some models also offer advanced pressure redistribution systems and reclining capabilities to prevent pressure sores and improve overall seating posture. • Stability and Safety Features: Safety is a paramount consideration in powered wheelchairs. These devices are designed with features such as anti-tip mechanisms, stability controls, and braking systems to ensure stability and prevent accidents. Additionally, they may include safety belts or harnesses to secure the user during movement. • Portability and Transportability: Many powered wheelchairs are designed to be easily disassembled or folded for convenient transportation in vehicles. This feature allows users to maintain their mobility and independence when traveling, visiting friends and family, or going on vacations. Portable models are lightweight and can be quickly assembled or disassembled without requiring specialized tools. Overall, powered wheelchairs and mobility devices have revolutionized the mobility options available to individuals with mobility limitations. Their advanced features, customization options, and versatile capabilities make them essential tools for promoting independence, accessibility, and inclusion in various environments. --- Smart Wheelchairs Smart wheelchairs integrate technology, sensors, and connectivity to enhance accessibility and user experience. These wheelchairs can incorporate features like obstacle detection and avoidance systems, automatic braking, and adjustable seating positions [35]. They may also utilize GPS and mapping technology to assist with navigation and route planning, enabling wheelchair users to explore unfamiliar environments with greater confidence. Here are some key points to understand in detail about smart wheelchairs: • Sensor Technology: Smart wheelchairs utilize sensor technology to gather real-time information about the wheelchair's surroundings and the user's movements. These sensors can include proximity sensors, ultrasonic sensors, infrared sensors, and cameras. The data collected from these sensors helps the wheelchair detect obstacles, navigate safely, and avoid collisions. • Obstacle Detection and Avoidance: One of the primary features of smart wheelchairs is their ability to detect and avoid obstacles in the user's path. The sensors integrated into the wheelchair's frame or wheels can detect objects or barriers and alert the user through auditory or visual feedback. Some advanced systems can even autonomously adjust the wheelchair's path to avoid obstacles, providing a higher level of safety and ease of navigation. • Automatic Braking Systems: Smart wheelchairs often come equipped with automatic braking systems that activate when obstacles or hazards are detected. These systems can assist in preventing collisions, especially in situations where the user may not be able to react quickly enough. The automatic braking feature adds an extra layer of safety and can significantly reduce the risk of accidents. • Navigation and Mapping Technology: Many smart wheelchairs incorporate navigation and mapping technologies to assist users in finding their way in unfamiliar environments. These systems may include GPS or Wi-Fi-based positioning, along with mapping software. Users can input their desired destination, and the smart wheelchair can provide turn-by-turn directions, highlighting accessible routes and points of interest. • Connectivity and Internet of Things Integration: Smart wheelchairs are often designed to be part of the Internet of Things ecosystem, enabling connectivity and interaction with other devices and systems. This connectivity allows users to control various aspects of the wheelchair, such as adjusting settings, monitoring battery life, and accessing diagnostic information remotely through Smartphone or other connected devices. • Personalized User Profiles: Smart wheelchairs can be customized to meet the specific needs of individual users. They often have the ability to store personalized user profiles, including seating positions, control preferences, and environmental settings. This customization ensures that the wheelchair provides a tailored experience for each user, optimizing comfort, support, and ease of use. • Integration with Assistive Technologies: Smart wheelchairs can seamlessly integrate with other assistive technologies and devices, enhancing their functionality and user experience. For example, they can be compatible with communication aids, environmental control systems, or smart home devices, allowing users to operate these technologies directly from their wheelchair. • Data Collection and Analytics: Smart wheelchairs can collect and analyze data regarding usage patterns, environmental conditions, and user behaviors. This data can be valuable for improving wheelchair design, user support, and overall wheelchair accessibility. Analyzing usage data can help identify usage trends, potential areas for improvement, and inform future advancements in smart wheelchair technology. Smart wheelchairs represent a significant advancement in wheelchair accessibility, providing users with enhanced safety, navigation assistance, and personalized features. By incorporating sensor technology, connectivity, and intelligent systems, these devices aim to improve the quality of life for individuals with mobility limitations and promote greater independence and inclusion in various environments. --- Assistive Robotics Advancements in robotics have led to the development of assistive devices that can augment the capabilities of wheelchair users. Robotic exoskeletons and robotic arms can assist with standing, walking, and performing daily activities. These technologies provide additional mobility options and promote independence for individuals with mobility limitations. Assistive robotics in the context of wheelchairs refers to the integration of robotic technologies and intelligent systems to enhance the functionality, accessibility, and user experience of wheelchairs [36]. It aims to provide greater independence, mobility, and convenience to wheelchair users. Here are some key points to understand in detail about assistive robotics in the context of wheelchairs: • Power-Assist Wheelchairs: Power-assist wheelchairs incorporate robotic systems to provide additional power and assistance to the user during propulsion. These systems can be either retrofitted onto manual wheelchairs or integrated into power wheelchairs. Power-assist technologies can include electric motors or actuators that assist with propulsion, reducing the effort required by the user to push the wheelchair. This feature is particularly beneficial for individuals with limited upper body strength or endurance. • Autonomous Navigation: Robotic advancements enable the development of autonomous navigation systems for wheelchairs. These systems utilize sensors, mapping technology, and intelligent algorithms to enable the wheelchair to navigate autonomously through indoor or outdoor environments. Autonomous navigation can include features such as obstacle detection and avoidance, path planning, and following predefined routes. This technology allows wheelchair users to navigate complex environments with greater ease and reduces their reliance on manual control. • Robotic Transfer and Lift Systems: Assistive robotics can be integrated into wheelchair transfer and lift systems to facilitate safe and efficient transfers between the wheelchair and other surfaces, such as beds, vehicles, or bath chairs. Robotic transfer systems utilize robotic arms and sensors to assist with lifting, repositioning, and transferring the user. These systems can help reduce the physical strain on both the user and caregivers during transfers, enhancing safety and independence. • Smart Wheelchair Controls: Assistive robotics enables the development of smart wheelchair control systems that incorporate advanced technologies for enhanced user control and customization. These systems can include intuitive control interfaces such as touchscreens, voice commands, or gesture recognition. They may also incorporate technologies like machine learning or artificial intelligence to adapt to the user's preferences and optimize the control experience. Smart wheelchair controls provide users with greater flexibility and customization options, making the wheelchair more user-friendly and accommodating individual needs. • Connectivity and Integration: Assistive robotics in wheelchairs can leverage connectivity and integration with other devices and systems to enhance functionality and user experience. Wheelchairs can be connected to the Internet of Things ecosystem, enabling interaction with smart home devices, environmental controls, or healthcare monitoring systems. This connectivity allows users to control their environment, access information, and communicate with others seamlessly from their wheelchair. • Environmental Adaptation: Assistive robotics can enable wheelchairs to adapt to different environments and terrain conditions. For example, wheelchairs can be equipped with robotic systems that automatically adjust seating positions or suspension settings to provide optimal comfort and stability on different surfaces. These adaptations can improve wheelchair performance and user comfort when navigating rough terrain, slopes, or uneven surfaces. • Human-Robot Interaction: As assistive robotics becomes more advanced, there is a focus on improving human-robot interaction in wheelchairs. This involves developing intuitive interfaces, such as speech recognition, touch screens, or gesture control, to enable natural and efficient communication between the user and the robotic wheelchair. Efforts are also being made to incorporate social cues and emotional interaction to enhance the user's experience and promote a sense of companionship and trust with the robotic wheelchair. Assistive robotics in wheelchairs holds tremendous potential in improving the mobility, independence, and overall quality of life for wheelchair users. By integrating robotic technologies and intelligent systems, assistive robotic wheelchairs provide users with enhanced functionality, autonomy, and convenience. They contribute to greater accessibility and inclusivity, enabling individuals with mobility limitations to participate more fully in society. --- Wheelchair Accessories and Add-Ons Innovative accessories and add-ons for wheelchairs have emerged to address specific challenges faced by wheelchair users. For example, ramps and lifts can be attached to vehicles to facilitate easy access and transportation. Wheelchair-mounted devices, such as tablet holders or communication aids, can enhance communication and access to information. Wheelchair accessories and add-ons refer to additional components or features that can be attached or incorporated into a wheelchair to enhance its functionality, comfort, and convenience [37]. These accessories are designed to cater to the specific needs and preferences of wheelchair users. Here are some key points to understand in detail about wheelchair accessories and add-ons: --- Seating and Positioning Accessories • Cushions: Wheelchair cushions are designed to provide comfort, pressure relief, and support for individuals who spend extended periods in a wheelchair. They come in various materials and designs, such as foam, gel, or air-filled cushions, to accommodate different seating needs. • Backrests: Backrests provide support to the user's back and help maintain proper posture while seated in a wheelchair. They can be adjustable, contoured, or have additional padding to ensure optimal comfort and spinal alignment. • Headrests: Headrests offer support to the user's head and neck, providing stability and reducing the risk of strain or discomfort during prolonged sitting. --- Mobility and Accessibility Accessories • Wheelchair Ramps: Wheelchair ramps facilitate easy access to buildings, vehicles, or raised platforms. They are portable or permanent structures designed to bridge height differences, allowing wheelchair users to navigate obstacles independently. • Transfer Boards: Transfer boards assist individuals in transferring from the wheelchair to other surfaces, such as beds or vehicles. They provide a smooth and stable platform for safe transfers, reducing strain on both the user and caregiver. • Wheelchair Lifts: Wheelchair lifts are mechanical devices that allow users to be raised or lowered to overcome architectural barriers. They are commonly used in homes, vehicles, or public spaces to provide vertical accessibility. --- Storage and Carrying Accessories • Wheelchair Bags and Pouches: These accessories attach to the wheelchair frame or backrest and provide storage space for personal belongings, such as wallets, phones, keys, or medications. They are designed to keep items secure and easily accessible while on the move. • Wheelchair Backpacks: Backpacks specifically designed for wheelchairs offer larger storage capacity and allow users to carry more items comfortably. They often feature adjustable straps or hooks for easy attachment to the wheelchair. • Wheelchair Drink Holders: Drink holders are designed to securely hold water bottles, cups, or mugs while the user is in the wheelchair. They prevent spills and allow individuals to stay hydrated conveniently. --- Safety and Visibility Accessories • Wheelchair Safety Belts: Safety belts or harnesses provide additional security and stability for the user while seated in the wheelchair. They help prevent falls or shifting during movement and ensure the user remains safely positioned. • Reflective Tape and Flags: Reflective tape and flags improve visibility of the wheelchair, especially in low-light conditions or during nighttime. They enhance safety by making the wheelchair more noticeable to pedestrians, cyclists, or drivers. --- Comfort and Support Accessories • Armrest and Legrest Pads: These accessories provide additional padding and comfort for the user's arms and legs. They help reduce pressure points, prevent skin breakdown, and enhance overall comfort during prolonged sitting. • Wheelchair Covers: Covers protect the wheelchair from dust, dirt, moisture, and sun exposure when not in use. They help prolong the lifespan of the wheelchair and maintain its cleanliness. --- Communication and Technology Accessories • Communication Devices: Communication devices, such as tablet mounts or specialized software, enable individuals with limited verbal communication abilities to communicate effectively. They may include text-to-speech, picture-based communication, or eye-tracking technology. • Smartphone Mounts: Mounts designed for smartphones allow users to securely attach their phones to the wheelchair, providing easy access to communication, navigation, or other smartphone functionalities. Wheelchair accessories and add-ons play a vital role in enhancing the comfort, accessibility, and convenience of wheelchair users. They cater to individual needs, preferences, and specific requirements, enabling users to customize their wheelchair experience and improve their overall quality of life. These accessories promote independence, mobility, and inclusivity for individuals relying on wheelchairs for daily activities. --- Internet of Things and Smart Home Integration The concept of the Internet of Things has expanded into the domain of wheelchair accessibility. Wheelchairs and assistive devices can be connected to IoT networks, allowing seamless communication and integration with smart home systems. This integration enables users to control home appliances, adjust lighting and temperature, and access various services through voice commands or mobile applications, improving convenience and accessibility [38]. Here's a detailed explanation of IoT and smart home integration in relation to wheelchairs: • Connectivity and Communication: IoT enables the seamless connection and communication between different devices and systems. In the context of wheelchairs, this connectivity allows the wheelchair to interact with other smart devices and systems within the home environment. Through wireless connectivity protocols such as Wi-Fi or Bluetooth, the wheelchair can exchange information and commands with other IoT-enabled devices. • Smart Home Automation: Smart home integration allows the wheelchair to be integrated into a larger ecosystem of smart devices and systems within the home. This integration enables the automation and control of various aspects of the home environment, providing convenience and accessibility for wheelchair users. For example, the wheelchair can be connected to smart lighting systems, thermostats, door locks, or security cameras, allowing the user to control these devices with ease. Through voice commands, Smartphone apps, or specialized wheelchair interfaces, users can adjust lighting, temperature, or security settings without physical effort. • Voice Control and Assistants: One of the key benefits of IoT and smart home integration is the ability to control devices and systems using voice commands. Wheelchair users can utilize voice assistants such as Amazon Alexa, Google Assistant, or Apple Siri to control their wheelchair and other smart devices. By using voice commands, users can navigate their home, control smart appliances, or access information hands-free, enhancing accessibility and independence. • Environmental Adaptation: IoT and smart home integration can facilitate environmental adaptation to meet the specific needs of wheelchair users. For example, the wheelchair can be integrated with smart sensors that detect the presence of the user and automatically adjust lighting or temperature settings upon entry. This automation ensures a comfortable and accessible environment for the user without the need for manual adjustments. • Remote Monitoring and Safety: IoT connectivity enables remote monitoring and safety features for wheelchair users. Through sensors and connectivity, caregivers or family members can remotely monitor the location, movements, or health parameters of the wheelchair user. This remote monitoring enhances safety, allows for timely assistance in case of emergencies, and provides peace of mind for both the user and their caregivers. • Energy Efficiency and Cost Savings: Smart home integration can contribute to energy efficiency and cost savings. For instance, by connecting the wheelchair to smart energy management systems, users can optimize energy usage in their homes. They can schedule energy-intensive activities, monitor energy consumption, or receive alerts to conserve energy. These features not only promote sustainability but also help users manage their energy bills effectively. • Personalization and Customization: IoT and smart home integration allow for personalization and customization of the wheelchair experience. Users can tailor settings, preferences, and automation rules to meet their specific needs and preferences. For example, the wheelchair can learn and adapt to user behavior, automatically adjusting seat positions, or providing reminders based on individual preferences. The integration of IoT and smart home technology with wheelchairs enhances accessibility, convenience, and independence for wheelchair users. It promotes a more inclusive and connected living environment, allowing users to control their surroundings, access information, and communicate seamlessly. IoT and smart home integration contribute to improving the overall quality of life for wheelchair users by empowering them to navigate their home environment with ease and efficiency. --- Virtual Reality and Augmented Reality : Virtual reality and augmented reality technologies hold potential for enhancing wheelchair accessibility. VR simulations can help designers and architects create accessible environments by experiencing and identifying potential barriers before construction. AR applications can provide real-time navigation assistance, highlighting accessible pathways, ramps, and accessible facilities in public spaces. --- Virtual Reality VR refers to a computer-generated simulation that immerses users in a virtual environment, providing a sense of presence and interaction within a digitally created world [39]. In the context of wheelchairs, VR can offer the following benefits: • Rehabilitation and Therapy: VR can be used in wheelchair rehabilitation and therapy programs to provide interactive and engaging exercises. Users can participate in virtual simulations that focus on balance, coordination, strengthening, and cognitive skills, promoting physical and cognitive rehabilitation. • Virtual Travel and Exploration: VR enables wheelchair users to experience virtual travel and explore various locations and landmarks around the world. It allows them to virtually visit inaccessible places, historical sites, or tourist destinations, providing a sense of adventure and exploration. • Gaming and Entertainment: VR gaming offers wheelchair users the opportunity to engage in immersive and interactive gaming experiences. With VR headsets and motion controllers, users can participate in virtual sports, adventures, and other gaming activities, enhancing entertainment options and promoting social interaction. • Virtual Social Interaction: VR can facilitate virtual socialization for wheelchair users. They can engage in virtual social platforms, attend virtual events, or communicate with others in immersive virtual environments, providing opportunities for social interaction and reducing feelings of isolation. --- Augmented Reality AR refers to technology that overlays digital information or virtual objects onto the real-world environment, enhancing the user's perception and interaction with the surroundings [40]. In the context of wheelchairs, AR can offer the following benefits: • Navigation and Wayfinding: AR applications can provide wheelchair users with real-time navigation and wayfinding assistance. Users can view digital overlays or directions on their mobile devices or AR glasses, helping them navigate through indoor or outdoor environments, locate accessible paths, or find points of interest. • Environmental Awareness: AR can provide wheelchair users with contextual information about their environment. For example, AR applications can overlay accessibility information on buildings or public spaces, indicating the presence of ramps, elevators, or accessible facilities, enhancing the user's awareness and accessibility. VR and AR technologies have the potential to transform the wheelchair experience by providing immersive and interactive opportunities for rehabilitation, entertainment, social interaction, navigation, and learning. These technologies enhance accessibility, engagement, and empowerment for wheelchair users, opening up new possibilities and improving overall quality of life. --- Empowerment and Advocacy for wheelchair accessibility Empowerment and advocacy for wheelchair accessibility are crucial aspects of promoting equal rights, inclusion, and improved quality of life for individuals who use wheelchairs. --- Empowerment Empowerment refers to the process of enabling individuals with disabilities, particularly wheelchair users, to gain control over their lives, make informed decisions, and exercise their rights [41]. Empowerment in the context of wheelchair accessibility involves: • Education and Awareness: Providing individuals with knowledge about their rights, available resources, and opportunities for participation empowers them to actively engage in advocating for their needs. Education and awareness campaigns can increase understanding and promote positive attitudes toward wheelchair users and accessibility issues. • Skill Development: Empowering wheelchair users includes providing them with the necessary skills and knowledge to navigate their environment, operate assistive devices, and advocate for their rights effectively. Skill development programs can focus on mobility training, self-advocacy, communication skills, and leadership development. • Self-Confidence and Self-Determination: Empowerment aims to build self-confidence and self-determination in wheelchair users. By recognizing their abilities, strengths, and potential contributions, individuals can take an active role in decision-making processes, express their preferences, and pursue their goals. • Access to Assistive Technology: Access to appropriate assistive technology, such as wheelchairs, mobility devices, and communication aids, is a crucial aspect of empowerment. Having access to the right tools and technologies enables individuals to maximize their independence, mobility, and participation in various aspects of life. --- Advocacy Advocacy involves promoting and defending the rights, needs, and interests of wheelchair users at individual, community, and societal levels [42]. Effective advocacy for wheelchair accessibility includes: • Policy and Legal Advocacy: Advocating for the development and implementation of inclusive policies, laws, and regulations that protect the rights of wheelchair users. This may involve engaging with policymakers, government agencies, and disability rights organizations to influence change and ensure the inclusion of accessibility provisions in various sectors, such as transportation, infrastructure, and public facilities. • Awareness and Attitude Change: Advocacy efforts focus on raising public awareness about the challenges faced by wheelchair users and the importance of wheelchair accessibility. This includes challenging stereotypes, promoting positive attitudes, and combating discrimination and stigma. • Collaboration and Networking: Building alliances and partnerships with other disability organizations, advocacy groups, and community stakeholders to amplify the voices of wheelchair users. Collaboration strengthens advocacy efforts, facilitates information sharing, and increases the collective impact of initiatives aimed at promoting wheelchair accessibility. • Accessible Built Environment: Advocating for the creation of an accessible built environment that includes wheelchair-friendly infrastructure, including ramps, curb cuts, accessible parking spaces, and barrier-free pathways. This involves engaging with architects, urban planners, and construction companies to ensure compliance with accessibility standards and guidelines. • Inclusive Transportation: Advocating for wheelchair-accessible transportation options, including accessible public transportation, paratransit services, and accessible taxi services. This includes advocating for the installation of wheelchair ramps, lifts, and securing spaces within vehicles to accommodate wheelchair users. • Social Inclusion and Participation: Promoting the inclusion and active participation of wheelchair users in various spheres of life, including education, employment, recreation, and social activities. This involves advocating for accessible educational institutions, workplace accommodations, and recreational facilities that cater to the needs of wheelchair users. Empowerment and advocacy for wheelchair accessibility are essential for promoting equal rights, creating inclusive environments, and ensuring that wheelchair users have the opportunities and support they need to live fulfilling and independent lives. By empowering individuals and advocating for systemic changes, we can work towards a society that embraces diversity, promotes accessibility, and upholds the rights of all individuals, regardless of their mobility challenges. --- Conclusion Wheelchair accessibility plays a vital role in bridging the gap to equality and inclusion for individuals with mobility challenges. This research paper has explored various aspects related to wheelchair accessibility and its significance in promoting equal rights, independence, and improved quality of life. The literature review highlighted the barriers and challenges faced by wheelchair users, including physical obstacles, social stigma, and inadequate infrastructure. It also discussed the importance of addressing these barriers through policy changes, awareness campaigns, and inclusive design practices. The research identified gaps in current knowledge and highlighted the need for further investigation to address these challenges effectively. Technological innovations such as powered wheelchairs, smart wheelchairs, assistive robotics, and wheelchair accessories have emerged as promising solutions to enhance wheelchair accessibility. These advancements have provided greater mobility, independence, and customization options for wheelchair users, improving their overall well-being and integration into society. Furthermore, the integration of Internet of Things and smart home technology, as well as virtual reality and augmented reality , have opened new avenues for accessibility and inclusion. These technologies offer enhanced navigation, environmental adaptation, social interaction, and learning opportunities for wheelchair users, empowering them to navigate their environments with greater ease and independence. Empowerment and advocacy have been identified as essential components of promoting wheelchair accessibility. Empowering individuals with knowledge, skills, and assistive technology helps them assert their rights, make informed decisions, and actively participate in society. Advocacy efforts aimed at policy changes, awareness raising, and collaborative partnerships play a crucial role in driving systemic improvements and promoting inclusivity. In conclusion, wheelchair accessibility is not just a matter of physical accommodations; it is about ensuring equal rights, dignity, and opportunities for individuals with mobility challenges. By addressing barriers, leveraging technological advancements, and promoting empowerment and advocacy, we can bridge the gap to equality and inclusion for wheelchair users. It is imperative for policymakers, designers, healthcare professionals, and society as a whole to work together to create a more accessible and inclusive environment that embraces diversity and upholds the rights of all individuals, regardless of their mobility limitations. Only through collective efforts can we create a society where wheelchair users can fully participate, thrive, and contribute their talents and abilities to the fullest extent. --- Practical Implication The research paper on wheelchair accessibility and its implications for bridging the gap to equality and inclusion has practical implications that can guide various stakeholders in their efforts to create a more accessible and inclusive environment. Here are some practical implications derived from the research: • Policy Development and Implementation: The research emphasizes the importance of developing and implementing inclusive policies that prioritize wheelchair accessibility. Policymakers can use the findings of this research to guide the creation of legislation and regulations that enforce accessibility standards in public spaces, transportation, and infrastructure [43]. Additionally, policymakers can advocate for the integration of accessibility considerations in urban planning and design guidelines. • Design and Construction: Architects, urban planners, and construction professionals can apply the research findings to ensure that buildings, public spaces, and transportation systems are designed and constructed with wheelchair accessibility in mind [44]. The research highlights the need for features such as ramps, accessible parking spaces, wider doorways, elevators, and tactile indicators to improve mobility and independence for wheelchair users. • Awareness and Sensitization: The research underscores the importance of raising awareness and sensitizing the public about the challenges faced by wheelchair users. Awareness campaigns can help dispel stereotypes, promote understanding, and foster empathy [45]. Educational institutions, community organizations, and media platforms can utilize the research findings to develop educational programs, workshops, and public campaigns that promote inclusivity and respect for individuals with mobility challenges. • Assistive Technology and Innovation: The research highlights the potential of assistive technology, such as powered wheelchairs, smart wheelchairs, and assistive robotics, in enhancing wheelchair accessibility. Manufacturers, engineers, and innovators can leverage this research to develop and improve assistive technologies that address the specific needs of wheelchair users [46]. By prioritizing user-centered design, these technologies can enhance mobility, independence, and overall quality of life for wheelchair users. • Training and Education: Healthcare professionals, caregivers, and rehabilitation specialists can utilize the research findings to enhance their training programs and services. The research underscores the importance of providing comprehensive training and education on wheelchair use, maintenance, and customization [47]. By equipping healthcare professionals and caregivers with the knowledge and skills to support wheelchair users, the research contributes to improving the overall care and support received by individuals with mobility challenges. • Collaboration and Partnership: The research emphasizes the need for collaboration and partnership among stakeholders involved in promoting wheelchair accessibility. Government agencies, disability organizations, healthcare providers, architects, educators, and community leaders can collaborate to create a comprehensive approach to accessibility [48]. The research findings can inform the development of collaborative initiatives, working groups, and partnerships that aim to bridge the gap to equality and inclusion for wheelchair users. By incorporating these practical implications into real-world initiatives, stakeholders can make tangible progress in improving wheelchair accessibility and fostering equality and inclusion. The research provides a foundation for evidence-based decision-making, ensuring that efforts are focused on the most effective strategies to create a more accessible and inclusive society for individuals with mobility challenges. --- Limitation While the research paper on wheelchair accessibility and its role in bridging the gap to equality and inclusion provides valuable insights, it is essential to acknowledge certain limitations that may impact the interpretation and generalization of the findings. Some limitations to consider include: • Geographic Context: The research may have focused on a specific geographic area, limiting the generalizability of the findings to other regions with different cultural, social, and infrastructural contexts. Factors such as urban versus rural environments, variations in accessibility standards, and legal frameworks may vary significantly across different locations, influencing the outcomes and recommendations of the research. • Methodological Constraints: The research may have employed specific research methods or data collection techniques that have their own limitations. For example, reliance on selfreported data or retrospective surveys may introduce recall bias or rely on subjective perceptions. Researchers may have also encountered challenges in accessing certain populations or obtaining accurate and comprehensive data on wheelchair accessibility. • Practical Implementation Challenges: While the research may offer practical implications, it is important to recognize that implementing these recommendations in real-world contexts can pose challenges. Factors such as financial constraints, lack of political will, resistance to change, or competing priorities may hinder the effective implementation of accessibility measures and initiatives. By acknowledging these limitations, future research can build upon the existing knowledge and address these gaps to provide a more comprehensive understanding of wheelchair accessibility and its implications for equality and inclusion. Additionally, researchers and stakeholders can be mindful of these limitations when interpreting and applying the findings to real-world scenarios, ensuring a nuanced and context-specific approach to promoting wheelchair accessibility. --- Future scope The research paper on wheelchair accessibility and its role in bridging the gap to equality and inclusion opens up several avenues for future research and exploration. The following are potential areas for future studies and investigations: • Inclusive Design: Future research can focus on advancing inclusive design principles and practices to improve wheelchair accessibility. This includes exploring innovative design solutions for public spaces, buildings, transportation systems, and other environments to ensure they meet the diverse needs of wheelchair users. Research can delve into the development of universal design guidelines and standards that prioritize accessibility and usability for individuals with mobility challenges. • Technological Advancements: As technology continues to evolve, there is a need for further research on the integration of emerging technologies into wheelchair accessibility. This includes studying the effectiveness and user experiences of technologies such as artificial intelligence, machine learning, and robotics in enhancing mobility, navigation, and overall accessibility for wheelchair users. Additionally, research can focus on the development and refinement of smart and connected wheelchair technologies that improve independence, safety, and comfort. • Intersectionality and Multiple Marginalization: Future research can explore the intersectionality of wheelchair users' experiences by considering factors such as gender, race, socioeconomic status, and age. Understanding how these multiple identities intersect and influence accessibility challenges and experiences can help develop more comprehensive and inclusive strategies for addressing the needs of individuals with diverse backgrounds and circumstances. • Global Perspectives and Cultural Variations: Expanding research to encompass global perspectives and cultural variations in wheelchair accessibility is essential. Investigating the challenges and best practices in different countries and regions can shed light on the cultural, social, and economic factors that influence accessibility. Comparative studies can facilitate cross-cultural learning and inform the development of context-specific approaches to wheelchair accessibility. By addressing these future research areas, we can further enhance our understanding of wheelchair accessibility and its implications for achieving equality and inclusion. This knowledge can inform evidence-based practices, policy changes, and interventions that foster a more accessible and inclusive society for individuals with mobility challenges. ---

This research paper investigates the impact of wheelchair accessibility on the overall well-being and quality of life of individuals with mobility limitations. The paper highlights the importance of wheelchair accessibility as a key determinant of independence, social participation, and overall societal inclusion. By examining the barriers and challenges faced by wheelchair users in various environments, including public spaces, workplaces, and educational institutions, this study sheds light on the profound implications of limited accessibility. Furthermore, it explores the benefits and potential outcomes of improved wheelchair accessibility, such as increased opportunities for employment, education, and social engagement. The research emphasizes the need for proactive measures, including policy reforms, infrastructure modifications, and awareness campaigns, to enhance wheelchair accessibility and break down the physical and attitudinal barriers that hinder full participation. By recognizing wheelchair accessibility as a crucial component of a more inclusive society, this research contributes to the ongoing dialogue and advocacy efforts aimed at promoting equal rights and opportunities for individuals with mobility impairments.

Context and Problem Statement Over the past forty years or so, a plethora of studies at the national and international levels have shown unambiguously the essential role of the family in terms of educational success and the crucial role of educators in providing support to parents in order to support their child better . This call for collaboration between schools and families is necessarily based on positive and constructive relationships between teachers and parents that are informative, collaborative and based on mutual trust and respect. There are in fact the essential conditions for the impact on educational success to be optimal . School-family partnership refers to family responsibilities and the role of the school in updating the involvement of parents in school work . However, the division of responsibilities seems more rhetoric than practice. As found in other countries like in Denmark , it seems that the responsibilities of sharing expectations have not materialized in all environments . How can such a situation be explained? Could unveiling accumulated tensions in the teacher-parent relationships facilitate partnerships? In Quebec , there is a strong political will to support parental involvement. In Legal provisions such as the Law on Public Instruction Act 124 adopted in 2002 in connection with the educational project and the success plan helped to expand the role of the governing board and of parents in relation to school . In the Quebec curriculum reform implemented in 2001 as well as in the publications of numerous documents such as School I care! -Together for Student Success , the Ministry of Education emphasizes the importance of parents in supporting students. In the Ministry of Education reference frame of 12 competencies that pre-service teachers must develop before entering the field. Especially Competency 9 requires teachers to involve parents and inform them about their child's success and school life. Expectations that are described go beyond information on programs, work at home, the school functioning rules and suggestions on how to help and support their child. There are also expectations of communications by letters or other contributions made by parents who show some talents or interests. They call for dialogue based on a relationship of trust that makes a division of labor with the family possible . Despite all of the above policies and official documents, some researchers do not believe that things have changed much over the past fifteen years . Indeed, comments brought to our attention, either by the media or by preservice teachers in return from their internship or by in-service teachers indicate expectations from parents, sometimes disproportionate to them, suggesting a predominance of the client approach adopted by many parents. --- Brief Review of Literature A great number of studies have focused on the identification of factors that may hinder effective teacher-parent relationships. These include, among others, some characteristics linked to youngsters , their families and their teachers . Other researchers haves examined the school and the teachers' practices implemented to promote parental involvement. One interesting finding was that many teachers still favor traditional modes of parental involvement, for instance, parental involvement in outings and fundraising . Also important are research results that have highlighted the fact that a clumsy participation can exacerbate divisions of power and reproduce inequalities between schools, teachers and parents . Obviously, collaborative work that requires the sharing of responsibilities between teachers and parents can be a source of tension . Likewise, the expectations with respect to each other are not always clearly expressed . It is the same with respect to responsibilities and the definition of their roles . From these fuzzy spaces emerge dilemmas and misunderstandings to which Ravn refers as ambiguous relationships. In the current study based on teachers' perspectives and situated at a micro-level, we are particularly interested in the predictive variables explaining teachers' motivations for promoting parental involvement and how they do it. For example, reviewed literature revealed that teachers' fear of being judged, of losing their professional autonomy, or lack of time and absence of support from a responsive school principal constitute barriers to teacher-parent effective relationships . At the same time, it becomes relevant to have teachers express their expectations regarding parents as well as describe their own implemented practices and the facilitating conditions as well as the challenges they meet in doing so. This research is in line with prior works on teacher burnout and teacher stress . Thus, Van der Wolf et al.'s works on the stress experienced by teachers in connection with parents report excessive and contradictory demands from parents and little recognition obtained in return. The actual study also goes along with previous researches that dwelled on the impact of educational reforms on changes in the relationship between teachers and parents. For example, Driscoll argued that empowerment of parents and the path to teacher professionalization exacerbates existing conflicts between teachers and parents. Especially when parents are from privileged backgrounds, their power as clients can affect the autonomy of teachers. In Addi-Raccah and Elyashiv-Arviv 's research, although teachers were supportive of parental involvement, they confessed to feeling vulnerable to the increased influence of parents and their intrusion into their professional field. Likewise, Baeck 's findings show that teachers try to keep welleducated parents at a distance in order to protect their professional autonomy. It becomes thus imperative to unveil the conflicts arising . One question is raised: What are the areas of tensions and inner contradictions that emerge in the school's teacher-parent relationships? Identifying these elements is likely to guide the teachers and the parents to engage in individual and collective transformation processes. --- Theoretical Frameworks The present study is anchored in two main theoretical models: 1) Hoover-Dempsey et al. 's proposed model of the processes influencing teachers' motivation for school-family partnerships, and 2) the cultural-historical activity theory . Hoover-Dempsey et al.'s proposed model suggests that teachers will foster collaborative relationships with parents in function of personal and contextual motivators and depending on some life context issues. Regarding personal motivators, teachers who believe that work with parents is part of their professional responsibilities, that they are expected to do so from both the school and the district leaders , and that they believe they can make a difference in actively supporting parents' involvement in students' learning , they will more likely work in that direction. Likewise, if teachers perceive school and district policies that support schoolfamily collaboration, as well as commitment from the school principal and a school culture that facilitates and values effective and collaborative teachers-parents relationships , they will be more inclined to develop that way. As for the life context issues, if teachers are prepared to engage in collaborative relationships with parents, that is, if they have the knowledge, the skills and the allotted time to invest in such relationships, they will be more inclined to go ahead. Even though all of the above processes might be at work for promoting collaborative relationships with parents, it doesn't mean that teachers will necessarily engage in agency to transform their work practices. In the light of CHAT, agency is broadly understood as encompassing almost any form of the human capacity to act intentionally . It is manifested when people form intentions and execute willful actions that go beyond and transform the accepted routines and given conditions of the activity and organization in which they are involved . Another important aspect to consider is that agency happens when individuals ascribe new meaning to their activity in order to overcome a conflictual situation . Interestingly enough, Barma, Lacasse andMassé-Morneau have documented that although teachers engage in agentive actions to modify their practice and feel confortable about it, unexpected tensions coming from parents may rise when roles and routines are changed in the classroom. Increased in interactions and communication between teachers and parents might contribute to an increase in the possibility of tensions and conflicts . Indeed, tensions tend to accumulate, to become systemic and recurrent and according to the theoretical framework of the cultural-historical activity theory and they are in fact the manifestations of dialectical contradictions . Contradictions are at the core of CHAT and are understood as part of any human activity. They are never directly accessible to a researcher but if they remain uncovered and unresolved, they will paralyze the on-going transformative processes in one's professional activity . This is why we turn to cultural-historical activity theory in order to better understand how they can be overcome and foster agentive actions . CHAT has also at its central point of interest the concept of activity . Activity theory proposes that learning activities are human activities socially situated, for example in relation to the world of labour or that of learning. It is a theoretical framework that focuses on new forms of learning and social practices developed beyond the activity of isolated individuals, and considers the historicity of a collective process of transformation . CHAT emphasized the distinction between individual and collective activity, considered that labour is essentially cooperative and characterized by division of labour between the individuals forming a collective. Engeström developed a systemic triangular model to understand human collective activity . The lower part of the triangle brings to light the essential mediating role played by the socioinstitutional dimension of human activity as community members engage in the pursuit of a new activity, change their roles and the way labour is redistributed amongst them. In third generation CHAT, an activity system is the unit of analysis and illustrates that human activity is goal-oriented and tool-mediated not only by individuals but also by collectives. Figure 1 presents the model of an activity system that is object-oriented, mediated by artefacts , community, rules and division of labour. Model of a Collective Activity System . --- Subject In Quebec, the object of the activity of teachers is still defined by their ability to have students perform at provincial standardised tests and assess disciplinary content. But as a new curricular reform took place in 2001, the requirements changed asking teachers to engage in more collaborative relationships with parents . In the context of this paper, such a situation presupposes a dual existence between two opposing types of relationships between teachers and parents for the production of a new form of relationships between teachers and parents: work in separate spheres of influence versus overlapping spheres of influence . This is an example of a first level of contradiction i.e. in the production of a new form of activity. The hypothesis we bring forward is the following one: since teachers appear to feel isolated and misunderstood, we wonder if parents act as clients or collaborators . --- Research Objectives The objectives of this research are as follows: 1. To identify elementary and secondary teachers' perceptions of the various factors and processes that interact in their relationships with parents in general. 2. To document the facilitating conditions and the challenges they meet in their relationships with parents in the light of potential new instruments, rules or division of labor in their work environment, and 3. To identify the conditions necessary to put into place so teachers and parents engage in reflecting on how they could better communicate and collaborate. To reach the first objective, we'll rely on Hoover-Dempsey et al.'s proposed model whereas to meet the second and third objectives, we'll build on the CHAT theoretical theory . --- Method --- --- Data Collection Data were collected using six semi-structured individual interviews. The individual interview technique was chosen because it allows exchanges between the interviewees and the interviewer in order to deepen a phenomenon . The interview protocol is based on Hoover-Dempsey et al. 's proposed model of teachers' factors and processes of school-family collaboration. It consisted of two main sections, a first one on the socio-demographic characteristics, and a second one on the processes associated with teachers' motivations to support collaborative teacher-parent relationships. This last section included questions on personal motivators, including their understanding of collaboration between teachers and parents, their role, their own practices and their expectations regarding parents' role; contextual motivators such as the school principal and colleagues support for the development and the support of collaborative teacher-parent relationships, and elements of their professional life context including questions about their knowledge, their skills and the allotted time and energy to work with parents. --- Procedures and Data Analysis Individual interviews with an average duration of about 75 minutes were conducted by the principal investigator in one of the teachers' union rooms made available to the research team during the months of May and June 2014. The teachers came in after their school hours or during their free time. Participants were asked to sign a consent form to ensure that their participation was based on a voluntary basis. They were first informed of the privacy standards and approval of the conduct of the study by the Ethics Committee of the Université du Québec à Trois-Rivières through certificate number: CER -14-201-07.05. The analysis was performed using the software NVivo. Coding is mixed , which means it was based on literature surrounding the sections of the interview protocol and illustrated in Hoover-Dempsey et al. 's proposed model while leaving out some room for new categories . Following the analysis of transcripts, five categories of items appeared in the section related to teacher-parent relationships in general: personal and contextual motivators, life context issues, teachers' practices, perceived parents' practices and risk factors associated with teachers and with parents. --- Results The findings of the study are first presented in line with Hoover-Dempsey et al.'s proposed model . At a second level, some findings are being discussed in light of the cultural-historical activity theory . --- Personal Motivators Subcategories include statements in connection with their understanding of teacher-parent collaborative relationships, their expectations regarding parents' role and the personal limits they have to apply. Different definitions are suggested. For one participant, collaboration means "to be on the same wavelength ; to follow-up on the child's work . For another, it is like teamwork . Another participant highlights the sharing of information between the teachers and the parents and vice versa, and focuses on the importance of communication . As for their expectations regarding parents' role, teachers wish that they provide all the school supplies that the child needs so that he/she comes to school ready to learn . They also wish that parents show interest in their child's schooling, , that they ask him/her questions about what went on at school, and that they accompany the child in his/her academic trajectories . They rely on parents to supervise homework, make sure homework is completed and handed in on time, and to motivate children / adolescents to go to school and to do well in school . They want parents to get in touch with the teacher if there is any kind of problem . For most teachers, expectations are rather traditional and more related to parental involvement in schooling at home and involvement in school projects. At the same time they recognize that working with parents is part of their professional responsibilities. However, they mention having sometimes to put some limits and let things go . In their opinion, parents in general are inclined to delegate to the teacher . --- Contextual Motivators This category includes the school principal support and school culture subcategories. Regarding the first subcategory, the participants' comments are not consensus. Two of them say that they do not have the support of their school principal to promote collaborative teacher-parent relationships . One teacher explains: "They are good managers, but they have difficulty with parents. They do not want to deal with parents. … Do your job correctly. Inform them, but do not take your problems to the principals' office." As for the school culture, the "client approach" seems to predominate in many schools in the sense that they are more at the service of parents than of children. One participant evokes: "I think they find it important that we have a lot of communication with parents and that we keep a good record of everything …: that seems their first objective. I think they don't want to have to do with parents." According to the participants, many teachers do not really want more communication, more collaboration with parents because the latter ones tend to overprotect their child and because there isn't enough support from the school principal . A teacher states that everything depends on the bond of trust between the teacher and the parent and that some teachers simply don't want to work with the parents anymore . Another one goes on saying that teachers don't have any contact with the parents anymore but at the same time, she claims that parents are too present in school . Certainly, many teachers communicate a lot via email. For some, this is understood more as a protective measure for teachers . A teacher deplores: "… I think something happened somewhere. Parents are taking up too much space in the school; they are too present ". A rather pessimistic view of collaboration with parents emerges from the above comments characterized by the presence of contradictions: on one hand, parental involvement is expected, but on the other hand, parents are said to be too present. --- Life Context Issues The elements of the professional life context are discussed in terms of time and energy and the perceived personal resources. Thus it happens that teachers refuse to promote collaboration with parents because of the heavy workload and lack of parent and principal support . Two participants even say "that teachers do not believe in working with families anymore, it has now become too difficult, too heavy, it takes time" . To work effectively with parents, teachers need to have self-confidence, a "strong" character, and to be diplomatic : "I think it takes a lot of self-confidence because parents constantly ask questions ". The participants say that they have to learn to protect themselves and to admit their mistakes if any and to learn from them . Active listening, knowledge of one's self and of one's limits and the ability to adapt and to make quick decisions are among other personal resources they deem important . As strategies, they recommend presentation of specific facts, planning ahead, excellent knowledge of the curriculum and careful observation skills . They acknowledge, however, lacking the resources and the training to work well with parents . --- Teachers' Practices This category relates mainly to the methods of communication being used with parents. The participants highlight the importance of communication between teachers and parents to provide and exchange information and to motivate both the child and the parent . For one teacher, communication is mainly conducted through email via the student-parent portal because of the need to keep traces, evidence, and to a lesser extent, by telephone . Others mostly use the student agenda and the telephone and they make sure to take into account the reality of families' lives . A teacher says to prefer to communicate by phone because human contact is crucial for her . Another one uses the studentparent portal to make available to the parents her weekly work planning and her expectations regarding students' work . This portal is an electronic platform usually located on the website of the school board that teachers are strongly urged to use to communicate with parents. One participant reveals: "The portal is helpful because it facilitates the follow-up by the parents" . Another one summarizes: "It doesn't matter which communication modes are being used: student agenda, e-mail, phone call…. I try to respond as quickly as possible. It is done in a respectable and timely manner; … some parents think we are always sitting behind our computer screen…" --- Perceived Parents' Practices The participants have mixed feelings regarding the state of the situation in terms of teacherparent relationships. Communication practices are at the heart of their comments. Their statements reflect different realities depending on the participants. One teacher says: "Usually, communication with the parent is going well." . For another participant, it is just the opposite: parents never return her messages . Moreover, a teacher working in disadvantaged areas reminds that she used to invite parents to come to school: "You come when you want. On my door, it says "open to parents"." It seems that not many parents showed up. A participant recalls that she invited a parent to read stories to the students. She was disappointed with the performance of the parent and felt uncomfortable because he didn't show any words or images. She has since given up on inviting parents in her classroom . For four teachers, communication with parents is more difficult and is far from being bidirectional. For example, some parents do not check messages on the portal regularly. A participant complains that there is no feedback from parents, although most of them have the email address to communicate with the teacher . It seems that the situation is more problematic with parents of children having difficulty in school: "Parents don't return messages … and there is not a lot of requests to meet the teacher" . Another one adds: "Communication is not there at all. It does not work. To be effective, it has to be on a frequent and continuous basis." . Furthermore, despite the large quantity of informative messages sent home, teachers very rarely get thank you notes from the parents . Other participants are outraged because some parents blame them when their child is not doing well in school. In some cases, participants say that parents do not help their children to take responsibility for school work and to consider school as a priority . It goes without saying that a low level of communication is often associated with a low level of parental involvement at least at the school level and in the school projects, as noted by the participants. --- Risk Factors Associated with Teachers and Parents Some teachers' comments reflect exhaustion as in the case of curriculum with particular pedagogical projects . The teachers' workload may be rather heavy and thus make them more vulnerable physically and mentally. Some participants think that the challenges linked to collaborative teacher-parent relationships are even more important when it comes to non-traditional families, especially since in their view, nearly a third of their students come from single-parent or stepfamilies . In shared custody situations, the teacher must duplicate information to both parents' addresses available on the portal. With respect to problematic parents, the parent as client is described by the participants as the parent who bothers them most, that is, who is troublesome. For instance, the parent client or customer goes first to the principal office when there is a problem instead of going to see the teacher: "They go to the school principal, they make their request. I feel like a salesperson in a store who should meet their demands, we're like a customer service ". Four teachers mention both the overprotective parent as client who throws all the responsibility on the teacher and the school, and never on the child . Often, these parents believe more in the fact version from their child than from the teacher: "The parent often takes the child's side" . --- Discussion Some of the most notable findings are now discussed in light of the cultural-historical activity theory . We have chosen to focus on the following areas of tensions according to the poles of an activity system and their interactions, for example: 1) Issues of trust versus control when it comes to choosing communication tools and pathways of communication between the members of the school family community, and 2) issues related to the hierarchical status and power inside and outside the school when it comes to the redistribution of actions among the school community members. Figure 3 presents the points of interest that will be discussed. --- Issues of Communication Right from the start, this study puts into evidence the complexity of relationships between teachers and parents, given the multitude of factors and processes that interact. We first note that the design of the teacher-parent relationships converges especially towards the communication and transmission of information from school to home. This view is reflected in the teachers' expectations regarding parental support, expressed in terms of interest, supervision, motivation, etc. These words echo what parents had themselves stated in terms of parental involvement in a previous study that was conducted almost 15 years ago . Indeed, the study participants had described their involvement in terms of interactions with the school, contribution to the motivation of the child, supervision as well as monitoring and prioritization of school work. So it seems that the school-family communication is still primarily unidirectional despite all the works showing the compelling nature of reciprocity and bi-directionality in communication in order to foster collaborative relationships between teachers and parents . There has been a trend over the years of teachers' obligation to define some parameters of their professional role alleging "too big shoveling in their yard" by parents. These comments are consistent with, among others, the works of Van der Wolf and Everaert indicating the sometimes unrealistic expectations on the part of some parents and the pressure put on teachers while contributing to the increase of their stress. They are also in line with Ravn's comments regarding teachers' and parents' necessity to share their expectations. In the light of CHAT analysis, the members of the school family community have to have a shared vision of what a collaborative relationship means to all of them. If parents consider themselves clients, then the contradiction in the activity of communicating will not be resolved and the teachers who will keep on feeling not trusted and isolated . Under the heading of contextual motivators, the collected perceptions suggest a lack of consensus on the issue of support or not from the school principal. Note a greater predominance of the lack of school principal support. The participants' comments correspond to the findings of studies showing on one hand, the importance of principals in giving support to teachers in their work with parents and in facilitating the development of trusting relationships with them and on the other hand, those that highlight the fact that some seem to have chosen to give priority to the principle of clientelism . In these circumstances, the role of mediator of the school administrator becomes marginal and while being pressured by some parents, he/she can hardly provide the support expected by the teachers . We postulate that these school administrators legitimize their low provision of support by the need to preserve their own status and their own credibility with their employer or the district school board at least in the context of the province of Quebec. In that light, the division of labor between the different members of the school family community has to be clarified. Are school principals imputable to parents or are they supposed to support teachers in their professional responsibilities regarding work with parents? With respect to a more tangible aspect of the instruments used to communicate with each other, the results put into light a large repertory of them but at the same time one needs to focus on how and when they are be used. Within the professional life context and risk factors associated with teachers, while putting forward communication with parents as the most important practice, participants acknowledge not having enough time, enough resources and enough training to work well therewith. Certainly they appear to use a variety of means of communication ranging from parent-student portal, e-mail, student agenda, memos and phone calls. According to some participants, means of communication are also seen as ways to keep traces in the event of any problems with parents. However, feedback and words of appreciation from parents are extremely rare. This lack of recognition appears to have a deleterious effect on the motivation of certain teachers. In addition, teachers complain that the consistency in communication is not present. This finding goes against the recommendations in many scientific papers on the need for clear, frequent and timely communication between teachers and parents . In sum, in the current study, communication with parents appears to be mostly one-way and for certain teachers, it is not only a way to discuss the students' progress and difficulties, but also a way to protect themselves in case of recriminations from parents. In the light of CHAT, we see two opposing forces at hand: trust versus control. --- Issues of Collaboration The client approach is also discussed by the vast majority of participants in their relationships with parents, under the angle of rules to be established. Parents too present, excessive demands, need for trust, these are words that corroborate data from previous works indicating discomfort among teachers caused by a greater power of specially, parents from privileged backgrounds who are usually more highly educated than other parents. According to Opltakea , these parents are more likely to act as customers. It is thus not surprising, as reported by the participants, that these parents function as clients , that is, they bypass teachers and prefer to speak directly to the principal, which is thereby a perceived threatening approach in the eyes of teachers. It is possible that this power, felt more importantly in affluent settings translate the frantic pace of everyday life leaving parents with very little time to exchange with teachers. In the light of our analysis based on CHAT, we see a contradiction in the division of labor: parents and teachers working in silo or choosing to work as a team? As another explanation, we could add the individualistic perspective from the parents' viewpoint at the expense of other students as a group in the same classroom . This individualistic vision is reflected especially in the client and overprotective parent who sometimes show mistrust towards the teacher. As noted by participants, this mistrust leads the parent to give more credibility to the child's version of events than to that of the teacher. Needless to say that countless studies have shown that the link of trust between teachers and parents is vital to collaborative school-family relationships and that it will necessarily impact on the way they share the different tasks between each other . --- Conclusion This study stands out in its originality in the use of two complementary theoretical perspectives, Hoover-Dempsey et al. 's proposed model of the processes influencing teachers' motivation for school-family partnerships, and 2) the cultural-historical activity theory that allows unveiling manifestations of tensions and contradictions that need to be addressed, thus facilitating transformative practices. Both models aim at deepening our understanding of complex human activities. The targeted outcome shared by the two models is the following object: collaborative teachers-parents relationships. It should be mentioned that the study has limitations that make it impossible to generalize the findings. These relate to the small size of the sample, to the great diversity of experience of the participants, of the contexts in which they work and the multiplicity of factors and processes that interact in relationships between teachers and parents. However, we stipulate that the data collection instrument, that is, the individual interviews conducted under the cover of anonymity, potentially provided an opportunity to the participants to open up and make statements, reveal ideas, that they would not have dared to express in other circumstances. This study shows that despite the advancement of knowledge on factors and processes related to collaborative relationships between teachers and parents, there are still and will always be elements that may contribute to tensions and dilemmas. It is necessary to admit that tensions and dilemmas are inevitable. Our results point in a particular way some elements that contribute to complicate relations between teachers and parents. First, there is this perception of mercantile ideology of the school that has emerged in several Québec schools representing parents as consumers, hence the name of the client approach. Focus on accountability for results, implementation of specific projects in schools, competition between schools, these are all measures put forward in order to better meet the customer needs. In a context of mercantile culture, it is not surprising that school principals choose to support above all parents in their recriminations, at the expense of teachers. As a promising avenue for intervention and developmental research, we suggest to apply the Change Laboratory method based on CHAT. This method relies on collaborative learning and transformation of work activities or practices . In the current situation, it aims at building on collaborative transformative agency based on a new understanding of the teacher-parent relationships and a new vision of its future development. Through the use of mirror data, the Change Laboratory method will allow the resolution of obstacles or barriers understood as discursive manifestations of contradictions in the discourse of the teachers and parents. Here a few elements that could become the starting points of a dialogue within the Change Laboratory sessions. For instance, it appears imperative to increase the awareness of school administrators to the importance of deploying with the teachers a leadership style that is based on humanist values characterized by "caring, empathy, encouragement and reinforcement". It is important not to wait for a political will at the provincial level, but to go forward with school principals who already provide support to their teachers in the work with parents and to hope for a snowball effect. It is also vital to better support parents in their parenting role and to sensitize them to the importance of prioritizing their children's schooling. This culture of clientelism seems to give more power to parents than they had in the past and to open the door to greater expectations and greater demands on the part of the whole society. It is a fertile ground for excessive requests and mistrust in the relationships between teachers and parents that are amplified by performance requirements and challenges associated with diverse family structures and situations. It is no longer just a dichotomy between advantaged and disadvantaged families but it is about conditions involving several risk factors interacting with each other and with processes. To create highly trusty links between teachers and parents, schools and teachers must explore the possibility to promote "repeated contacts as during meetings, face-to-face interviews, discussions, telephone conversations, written comments, participation in educational activities, social or other " Once again, it is an illusion to think that we will overcome or eliminate any possible dilemma between teachers and parents. There will always be different types of parents who pose additional challenges for teachers. It is likely that these challenges will increase in number in time of political austerity era as announced by the current provincial government while service cuts are already planned regarding students having difficulties. Furthermore, there are no guides, no programs or ready-made kits with key in hand regarding the development of collaborative relationships between teachers and parents, but rather general principles to which partners, teachers and parents are invited to adhere . We must not forget that students and their parents are constantly changing in function of student age and student school trajectory. As time goes by, so do students and their parents. Everything has to be done all over again, all the time.

Collaborative relationships between school and families are increasingly put forward as a means to promote student success and persistence. This collaborative work sometimes creates tensions and misunderstandings (Ravn, 2005) that can exacerbate divisions of power and reproduce inequalities (e.g., Crozier, 2000;Lareau, 2011;Vincent 2000). The main purpose of this study is to identify the areas of tensions and inner contradictions that emerge in the teacher-parent relationships in order to guide them while engaging in individual and collective transformation processes. Relying on Hoover-Dempsey et al.'s proposed model ( 2010), we conducted in-depth interviews with volunteered elementary and secondary teachers. Salient findings are discussed in light of the cultural-historical activity theory (CHAT) (Engeström, 2015). These include mainly issues of trust versus control when it comes to choosing communication tools and issues related to the hierarchical status and power inside and outside the school when it comes to the redistribution of actions among the school community members. As a promising research and intervention avenue, the authors suggest to apply the Change Laboratory method (Virkkunen & Newnham, 2013) anchored in CHAT and that uses mirror data to reflect upon and foster transformative processes, hence, relationships between teachers and parents.

Commentary In this issue, Azal Ahmadi [1] reports on the practice of hymenoplasty-a surgical intervention meant to restore a presumed physical marker of virginity prior to a woman's marriage. As Mehri and Sills [2] have stated, these women "want to ensure that blood is spilled on their wedding night sheets." Although Amadi's research was carried out in Iran specifically, this surgery is becoming increasingly popular in a number of Western countries as well, especially among Muslim populations. [3] What are the ethics of hymen restoration? Consider the role of the physician. Two of the doctors interviewed by Ahmadi reported being in "a perpetual state of guilt because of the surgery's inherent aim at deceiving the groom" and noted their "personal conflict" at being involved in this deception. Yet: "None of the doctors believed that the surgery was unethical, arguing that the girl could be 'abused' and 'can even die' if she is discovered not to be a virgin on her wedding night. One stated that a woman's 'life path can be changed' by this simple 30 min surgical intervention ..." From the doctors' perspective, then, the surgery is morally permissible. And on a simple harm/benefit analysis, it certainly is. That is, given the stigmatization involved-as well as the power of credible threats of violence to rig the arithmetic-one could hardly reach a different conclusion. But lurking in the background is a set of profoundly problematic social norms that should not be simply taken for granted in reasoning through this case. In other words, the ultimate source of harm in this example is not the absence of a girl's hymen in any particular instance, but rather an ugly suite of discriminatory attitudes and patriarchal social conventions. These attitudes, including a lopsided preoccupation with female virginity, are deferred to, perpetuated, and reinforced every time a girl's hymen is surgically 'restored'. What is a forward-thinking physician to do? A doctor's obligation is to her patient. If a woman's well-being would be seriously compromised by being denied this 'simple' procedure, then there are grounds for carrying it out on a case-bycase basis-so long as it is done safely, voluntarily, and under conditions of informed consent. But doctors are also members of a larger society, and they have a concomitant obligation not to profit from sexist hypocrisy. Stated generally: How can physicians promote individual patient welfare without becoming complicit in the perpetuation of unjust social norms? Consider breast implants-a more familiar example. As Murray [4] states: "Surgically sculpting one's body to resemble more closely idealized images of youthful slenderness and firmness may help an individual to feel good ... [but] surgically reshaping women's bodies to resemble Barbie dolls would make surgeons complicit [with reinforcing harmful social norms] along with the women whose bodies are being altered." Rather than turning to surgery, therefore, women should fight against those norms of physical appearance that are at the root of so much trouble. Problematically, however: "... surgeons and others are thrown into [a quandary] when we accuse them of complicity with unjust norms: sometimes patients are suffering, are seriously disadvantaged because these norms, however unjust, weigh down their lives. ... If an intervention can alleviate suffering-even if that suffering comes about only because of oppressive and unjust social norms-why should not clinicians do what helps their patients?" [4] Feminist philosophers such as Margaret Olivia Little [5] have tried to resolve this sort of dilemma. By questioning how much personal well-being in the here-and-now should be sacrificed on the altar of future, society-wide progress in changing problematic norms, Little's recommendation is double-pronged. She argues that medical professionals should "protest against and avoid promoting or profiteering from unjust norms" even as "they assist their patients in pursuing them." [4] This may be the best a physician can do. If a woman asks for a hymen reconstruction as a way to escape genuine and unavoidable harm, her doctor must take seriously the risks involved in not performing the procedure. But to offer such hymenoplasty ethically, doctors have further work to do. First, to avoid profiteering, they should charge the minimum possible fee for the surgery. Second, they should take concrete steps-such as donating to appropriate charities, or writing public editorials-to combat the outdated and discriminatory norms that are driving women to request such interventions in the first place.

What are the ethics of hymenoplasty? In this commentary, I argue that doctors must take seriously the risks involved in not performing the procedure when stigmatization and credible threats of violence are at stake. However, the ultimate source of harm in this example is not the absence of a girl's hymen, but rather an ugly suite of discriminatory attitudes and patriarchal social conventions. Therefore, doctors who perform hymenoplasty must take care not to profit from these unjust norms. I conclude by recommending that physicians charge the lowest possible fee for the procedure, while taking active steps to combat the problematic social norms that drive women to request hymenoplasty in the first place.

INTRODUCTION Access to Basic Education Globally, millions of school-age children face deprivation of educational opportunities due to armed conflicts and natural calamities, with an estimated 27 million children unable to attend school in conflict-affected areas . Armed conflicts, though declining between nations, persist with significant consequences, particularly in regions such as the Middle East, the Balkans, and Africa . The education sector is notably impacted, as evidenced by crossnational analyses linking intercommunal conflict to reduced school attendance . Conflict-related repercussions extend to attacks on educational institutions, faculty members, and students in nations experiencing civil war, such as Niger, Congo, Nigeria, Afghanistan, Colombia, and DR Congo . Access to quality education is seriously jeopardized in conflictaffected countries like Somalia and Sudan . Intercommunal conflicts not only hinder access to education but also affect its quality by diminishing resources through the destruction of facilities and displacement of education stakeholders, leading to a reduction in overall educational attainment . The government's diversion of resources meant for education to address security and humanitarian aid further exacerbates the situation, reflecting both the direct and indirect impacts of conflict on education . --- Conflict and access to Education in Africa Report on Children and Armed Conflict highlighted 2018 as the worst year for children affected by armed conflict, with about 250,000 students impacted by school closures in Mali alone. Despite the recognized importance of investing in education to mitigate conflict, armed groups like Boko Haram in Nigeria and the Taliban in Afghanistan and Pakistan actively target schools in their attacks . Conflict disrupts access to --- LITERATURE REVIEW Access to Basic Education The first nine years of formal education are classified as basic education, comprising two levels: Level 1, equivalent to elementary education, and Level 2, corresponding to lower secondary school . This initial phase, primarily provided through primary education, plays a crucial role in shaping individuals' future learning and cognitive development. UNHCR emphasizes the significance of basic education in raising public awareness, fostering self-improvement, reducing chronic and intergenerational poverty, and addressing fundamental insecurities associated with illiteracy and innumeracy. Access to basic education not only establishes the foundation for literacy and numeracy but also allows for the identification of gifted and struggling young minds, enabling timely corrective measures . However, challenges persist in achieving universal access to basic education, with estimates suggesting a need for millions of additional primary school teachers, particularly in Sub-Saharan Africa and South Asia . This underscores the ongoing struggle to ensure comprehensive basic education globally and the potential consequences of limited access for both individuals and society as a whole. --- Family Income Levels and Learning of Primary School Going Children According to Shuani , there are three types of household income and these are Real Income, Money Income and Psychic Income. Money Income is an individual or a household's purchasing power over a given period of time. Money income is therefore all earnings accruing to a family in the form of any medium of exchange over a specified period of time. These may include wages, profits, salaries, sick benefits, rent, interest, pensions, gifts, dividends, royalties, securities. Real income refers to the quantity of consumer goods, services, and public goods and services that are available during a particular time period. Both consumer and producer items make up real income. The happiness that a family experiences as a result of using their actual and financial resources is known as psychic income. Psychic income is intangible and subjective since it varies from one individual to the other and is also referred to as enjoyment income. This revenue is the result of a period of time's worth of proper use of real and monetary income.. Han and Lv used an empirical study of CHNS data in China to investigate how family income influences children's schooling. According to the study, a child's educational attainment is significantly influenced by family wealth. The study also shown that raising family income can raise the children's educational attainment in those homes.. It also shown that, despite the fact that parental money has little bearing on children's academic performance, rising income does have a higher impact on raising children's educational attainment. A family that is financially secure may offer more, particularly in the area of educational resources. On the other hand, low-income families must choose between providing for their families' needs and sending their children to school, and frequently they may prioritize providing for their own needs. The study, however, was conducted in a developed country as compared to the current study. In their study, Jurges, Stella, Hallaq, and Schwarz explored the impact of violence on primary school performance among children in households, specifically focusing on the severity of the Israeli-Palestinian conflict during the Second Intifada in the West Bank. The researchers utilized family income as a categorical variable, analyzing its net monthly impact. The study revealed that heightened exposure to conflict had a lasting effect on the long-term educational achievement of children. Another study conducted by Marbuah , using data from the Ghana Living Standards Survey 2012/2013, investigated the relationship between parents' income and their children's educational success in Ghana . The research found a positive correlation between parental income and academic success, emphasizing the role of income levels in shaping educational opportunities and learning resources for students as parents directly contribute to supporting their children's education. These studies collectively underscore the critical influence of contextual factors, such as conflict and income, on children's educational outcomes.. At Haramaya University in Eastern Ethiopia, Gobena looked at the effect of a family's socioeconomic position on students' academic achievement. The research method used was a descriptive survey. The study found no evidence that learners' academic achievement was directly influenced by their family's socioeconomic condition. In nomadic regions, raising livestock, growing cereal crops, conducting small-scale business, and raising other associated cash crops were the major economic activity However, the poor infrastructure and lack of market led to little or no sufficient income from these activities and this negatively affected learning at the university as some of the students could either not attend college or would be involved in activities to sustain their families. The study was however conducted on a University and was carried out in a different geographical location. Galgallo examined the factors affecting pupils' retention in Kenya's arid North-Horr District and Marsabit County public primary schools. Eight head teachers, 44 instructors, and 96 students in class 8 made up the research sample. Due to starvation, parents betrothed their daughters, which resulted in early pregnancies and underage prostitution among enrolled students. The study discovered that the loss of a household's main source of income has a substantial influence on student retention rates in public elementary schools in dry areas.. The study came to the conclusion that students' participation in home economic activities had an impact on retention rates in public elementary schools in dry areas. The study however, was not in the context of intercommunal conflict. --- Summary of Literature Gaps With respect to the effect of family income levels on access to basic education in the context of intercommunal conflicts, the followings gaps emerge. Han and Lv --- THEORETICAL FRAMEWORK --- Relative Deprivation theory This study was based on the Relative Deprivation theory of conflict by a Sociologist Samuel A. Stouffer ). Relative Deprivation theory gives a description that is built on the difference among groups projected and real access to wealth and influence. If it could be, countries known for wars would be the most racially dissimilar which in fact not the case is. Definitely, it may well be that ethnic and spiritual fractionalization even decreases the danger of fierce war , possibly since it inspires different sets to get to know the abilities of living together regardless of cultural differences . Once such knowledge course flops, nonetheless, cultural multiplicity may lead to exacerbation of war and upsurge the probability of stern growth, exactly because it brings about fertile material for political recruitment . This theory is applicable to this study in that in areas in which minorities' experienced economic bias, inequalities in living standards contrary to other tribes, and unbalanced provisions of national opportunities like land and wealth, inter-ethnic war was more possible to erupt. Such circumstances triggered tribal politics, and served to marshal a society's supporters. This increased the chances of the war intensifying from the prevailing tribal pressures. These tensions that lead to conflict have adverse effects on schools, pupils and teachers. --- System Resource Theory The study used Yutchman and Seashores' System Resource Theory . According to the notion, achieving organizational goals requires making an effort to find, share, and efficiently use limited resources. According to the theory, institutions like inputs like human, physical, and material resources are changed in schools. to produce desired outcomes. Similar to a business, schools use inputs to get desired results . After being accepted into a school, students engage with the teaching and learning materials, which produce learning outcomes. A school can achieve quality learning results if Its material and physical resources are sufficient and well used. Academic achievement is regarded as a yardstick for a good education all over the world. The achievement or failure of students reveals how resources have been used.. --- Hierarchy of Needs Theory Abraham Maslow's Hierarchy of Needs Theory serves as the basis for this investigation . According to Maslow, there are certain fundamental needs that must be met in order to live decently. They are sometimes referred to as physiological requirements. These include things like food, housing, and healthcare. Prior to addressing other wants like security, love, affection, and self-actualization, these needs must be met. This theory is pertinent to the research since it contends that basic needs, such as those for food, shelter, and security, must first be met before considering attending school. Failure to meet these needs would foster a lack of interest and commitment to education by all the education stakeholders. In a conflict prone area like Kapedo, conflict over community resources causes families to flee and become homeless. Businesses and other economic activities are also affected by the inter clan conflicts. These affect the provision of the basic human needs which end up affecting access to education and learning of primary school going children. --- RESEARCH METHODOLOGY --- Research Design A descriptive survey research design in the context of one organization was adopted for the study. The study examined access to basic education in the context of intercommunal conflict and the learning of primary school-going children in Kapedo ward of Turkana County. The design was appropriate since it aided in the management of quantitative data gathered through questionnaires. The design was a quick and inexpensive way of investigation, and the researcher had complete control over subject selection. --- Variables/Categories of Analysis The study variables were as follows. The independent variables were availability of learning resources and facilities, family income levels, cultural practices and tradition, and staffing rates. The dependent variable of the study was learning of primary school-going children. The study was carried out among Head teachers and Teachers of schools in Kapedo ward, Turkana East Sub County, as well as Ministry of Education Officials in the area. The categorical variables of the study included gender, age group, and educational level. The discrete variable had five levels, and thus was treated as a continuous variable. Treating the predictor as continuous variables implied that regression analyses were computed in the relationship between the response and the predictor. --- Target Population The study's target population included 24 teachers, 2 Ministry of Education officials, and 4 head teachers. Kapedo ward domiciled four basic education institutions: These were Kapedo Girls Primary School, Kapedo Mixed Boarding Primary School, Silale Primary School, and Lomelo Primary School. --- Sampling Techniques and Sample Size In consideration of the small population sample size, the study employed the census approach, and thus, the entire population was studied. The study respondents consisted of 2 Ministry of Education officers , 4 Head teachers, and 24 teachers. --- Data Collection For this study, semi-structured questionnaires and an interview schedule were employed as data collection methods. The majority of the data gathered was qualitative data. The interview schedule was used to obtain information from Ministry of Education officials and Head teachers, while the questionnaire was utilized to collect data from the teachers. A pilot research was carried out in the surrounding Nadome region with 10% of the study sample. The data collected were used to improve the quality of the research tools. --- Validity & Reliability The study presents its approach to ensuring the validity and reliability of the instruments used. Construct and content validity of the questionnaire were established through collaboration with approved college research supervisors, with a focus on enhancing the instrument's quality by eliminating unclear items. Reliability was assessed using the test-retest approach, and a correlation coefficient of 0.7 or more was considered strong, indicating the suitability of the questionnaire for data collection. --- Data Analysis and Presentation The questionnaire's quantitative data was updated to remove discrepancies. The replies were edited to ensure that they are accurate, comprehensive, and appropriate for further processing. The Statistical Package for Social Sciences version 25 software was then used to code and analyze quantitative data. The researcher analyzed the data using both inferential statistics , and descriptive statistics . The results for quantitative analyses were presented in the form of charts and tables. The following was the regression model: Y= β0 + β2X2+ ε Where: Y= Learning of primary school children X2 = Family Income Β0 = Constant β2 = Coefficients of determination ε= Error Term Qualitative data was analysed using textual analysis and presented in prose form. --- RESULTS --- Response Rate The study achieved a 100% response rate from the Ministry of Education Officials, Head Teachers, and Teachers in Turkana County, who showed a high level of interest and cooperation in addressing the issue of intercommunal conflict and its impact on access to education. The data collected from the respondents is expected to provide reliable and valid information for the study, and to inform policy and practice for improving access to basic education in conflict-affected areas. --- Demographic Characteristics The findings show that the respondents are predominantly male , which indicates a gender imbalance that may affect the study's results and implications. The gender distribution should be taken into account when analyzing the data and addressing any gender-specific issues related to education and conflict. It was shown that the respondents have a diverse age range, with most of them being between 26 and 35 years old or between 36 and 55 years old . The age diversity can help to identify any variations in perspectives or experiences among different age groups regarding education and conflict. The age distribution also reflects the typical age group of teachers in educational settings. The results show that the respondents have different levels of academic achievement, with most of them holding a certificate or a diploma , and only a few having a degree . The academic qualifications may influence the respondents' insights and opinions on education and conflict. The academic background of the respondents should be considered when interpreting the findings and ensuring their relevance. It was found that the respondents have different lengths of employment at their current educational institutions, with most of them having less than 5 years or between 11 and 15 years of experience. The employment length distribution is relatively balanced, which can help to reduce the bias related to experience affecting the results. The employment length distribution also suggests that the sample is representative of the educational workforce in the region. The paragraph also cites a recent study by Kipkoech et al. that shows the high turnover rate of teachers in Kapedo schools due to conflicts. --- Frequency of Conflicts The frequency of conflicts in the studied area is a crucial aspect to consider when assessing their impact on education. The responses from various key informants provide insights into the nature of these conflicts. According to the Resp 1, the conflicts tend to occur sporadically, lacking a fixed pattern or schedule. Similarly, the Resp 2 notes that the conflicts vary in frequency but have occurred periodically over the years. Head Teachers 1, 2, and 3 also emphasize the irregular nature of conflict incidents, with instances of intensity when they do happen. HT 4 further added that conflicts occur intermittently, making it challenging to predict when they'll take place. This varying and unpredictable frequency of conflicts raises important questions about their potential disruptions to the educational process and underscores the need for adaptive strategies to mitigate their impact on students and schools. The respondents were asked to provide their perspectives on the frequency of conflicts in the area. The question posed to them was, "How often do the conflicts occur?" Their responses revealed varying viewpoints on the matter. Resp 1 mentioned that conflicts in the area occur sporadically, without adhering to any fixed pattern. This implies that the conflicts are not predictable and may happen at irregular intervals. Resp 2, shared that the conflicts exhibit a varying frequency but have occurred periodically over the years. This response suggests that there is some degree of consistency in the occurrence of conflicts, even though they are not strictly regular. HT 1 expressed that conflict incidents have taken place irregularly, but when they do happen, they can be quite intense. This response highlights the unpredictability of the conflicts and the potential for them to escalate.HT 2, noted that the conflicts have no specific schedule and happen unpredictably. This emphasizes the absence of any discernible pattern in the conflicts' occurrence. HT 3 indicated that the frequency of conflicts can be sporadic, without following a set pattern. This response aligns with the notion that conflicts are sporadic and lack predictability. Finally, HT 4 stated that the conflicts occur intermittently, making it difficult to predict when they will happen. This response underscores the irregular nature of conflicts in the area. It is evident that there is a consensus among the respondents that conflicts in the area do not follow a fixed or predictable pattern. The terms used, such as "sporadic," "irregular," and "unpredictable," all convey the idea that the occurrences of conflicts are not easily anticipated. However, some respondents also pointed out that there may be periods when conflicts occur with more intensity, which could have implications for the community's preparedness and response strategies. These diverse perspectives provided by the respondents offer valuable insights into the nature of conflicts in the area, emphasizing the need for flexibility and adaptability in managing and mitigating such events. --- Descriptive Statistics for Family Income Levels The findings regarding the impact of reduced household income due to conflicts on families' priorities for children's education suggest that, on average, respondents are in agreement that economic instability resulting from conflicts noticeably affects how families allocate resources for education. This aligns with a study in Kenya conducted by Ndung'u and Njoka , which found similar effects of conflict-related income reduction on education priorities, highlighting the relevance of these findings. When examining the statement concerning the influence of a shift in family financial status due to conflicts on pupils' school attendance, the mean score of 3.375 indicates a general agreement among respondents that changes in family financial status due to conflicts influence school attendance among pupils. These findings are consistent with a study by Chege and Sifuna , emphasizing the role of economic factors in determining school attendance in conflict-prone regions in Kenya. The assertion regarding the impact of reduced family income due to inter-communal conflict on parents pushing their children into early marriage at the expense of schooling yielded a mean score of 3.3333. This mean score suggests that respondents, on average, agree that reduced family income resulting from inter-communal conflicts contributes to parents pushing their children into early marriages instead of prioritizing their education. This aligns with a study in Kenya by Kiplagat et al. , which found that conflict-induced poverty often leads to early marriages among girls, supporting the findings in this study. Regarding whether reduced family income due to intercommunal conflict leads to girls dropping out of school due to pregnancies and involvement in prostitution, the mean score of 3.7083 indicates that respondents, on average, agree that reduced family income resulting from inter-communal conflict has serious consequences for girls' education and well-being. This finding is consistent with the results of a study conducted by Mwenda and Njiru , which highlighted the association between conflictrelated poverty and girls' dropout rates in Kenyan schools. On the impact of the loss of household livelihood on the retention levels of students in public primary schools, the mean score of 3.6250 suggests that respondents generally agree that the retention levels of students in public primary schools are affected by the loss of household livelihoods. This finding is in line with a study by Ondari-Okemwa and Nyagah in Kenya, which emphasized the adverse effects of livelihood loss on student retention, reinforcing the importance of addressing economic stability to improve educational outcomes. The results regarding reduced family income leading parents to prioritize food and shelter over educational provisions for their children recorded a mean score of 3.6250. With this mean score, respondents, on average, agree that economic challenges often overshadow investments in education, particularly in meeting basic needs. These findings are consistent with a study by Kamau and Njoroge , which highlighted the trade-off between economic survival and educational investments in conflictaffected areas of Kenya. The interview schedule participants were asked about the impact of armed conflict on household income. The Quality Assurance and Standards Officer pointed out that armed conflict often leads to economic instability, which negatively affects household income. The Zonal Officer concurred, stating that household income can decrease due to conflict, as it disrupts economic activities. The head teachers, represented by Head Teachers 1, 2, 3, and 4, echoed similar sentiments, emphasizing that conflict tends to reduce opportunities for livelihoods and income sources, leading to financial strain for households. --- Qualitative Responses The question of how armed conflict affects household income is a complex one, as different factors can influence the economic outcomes of households in conflict-affected areas. However, based on the results from the Resp 1, Resp 2, and the four Head Teachers, the analysis was as follows. The respondents generally agreed that armed conflict has a negative impact on household income, as it disrupts the normal functioning of the economy and reduces the opportunities for livelihoods. Resp 1, stated that armed conflict often leads to economic instability, while the Resp 2 mentioned that household income can decrease due to conflict. The four Head Teachers also expressed similar views, noting that conflict tends to reduce the sources of income for households, especially those dependent on local economic activities. Therefore, the respondents suggested that armed conflict can cause a decline in household income, leading to financial strain and hardship for many families. The participants were asked about how changes in family income due to conflict affect the learning of primary school-going children. The Resp 1 and Resp 2, highlighted that reduced family income can limit children's access to essential educational resources and services. The respondent 2, Resp 2 expanded on this by mentioning that decreased income can result in children facing challenges in accessing educational materials and support. The head teachers, represented by Head Teachers 1, 2, 3, and 4, reiterated these points, emphasizing that lower family income can hinder students' ability to access necessary school supplies, meet their educational needs, and may create financial barriers that affect their educational progress. The question of how the change in family income due to conflict affects learning of primary school-going children is an important one, as it relates to the quality and equity of education in conflictaffected areas. Based on the results from the Resp 1, the Resp 2, and the four Head Teachers, the analysis of their opinions was as follows. The respondents generally agreed that reduced family income can have a negative impact on the learning of primary school-going children, as it can limit their access to essential educational resources and services. The Resp 1 stated that reduced family income can limit access to educational resources and services for children, while the Resp 2 mentioned that decreased income can result in children facing challenges in accessing educational materials and support. The four Head Teachers also expressed similar views, noting that lower family income can hinder students' ability to access necessary school supplies and support their learning, lead to students facing difficulties in meeting their educational needs, and result in students experiencing financial barriers that affect their educational progress. The respondents suggested that the change in family income can limit students' access to educational resources and opportunities, which can have adverse effects on their learning outcomes and well-being. The participants were asked to indicate in what ways the change in family income due to conflict affect learning of primary schoolgoing children? This qiestion addresses the impact of changes in family income due to conflict on the learning of primary schoolgoing children. The responses from various educational stakeholders consistently highlight that reduced family income can have adverse effects on children's education. The Quality Assurance and Standards Officer points out that this decrease in income has the potential to restrict students' access to crucial educational resources and services, which may, in turn, impede their learning. The Zonal Officer adds that decreased income can lead to challenges in accessing educational materials and support, affecting the educational experience of children. The question of how the change in family income due to conflict affects the learning of primary school-going children is an important one, as it relates to the quality and equity of education in conflict-affected areas. The results from the Resp 1, the Resp 2, and the four Head Teachers show that they all emphasize that lower family income can restrict students' access to necessary school supplies, affecting their educational progress. This consistent feedback underscores that the change in family income due to conflict is a significant factor influencing children's education. The Resp 1 stated that reduced family income can limit access to essential educational resources and services for children, while the Resp 2 mentioned that decreased income can result in children facing challenges in accessing educational materials and support. The four Head Teachers also expressed similar views, noting that lower family income can hinder students' ability to access necessary school supplies and support their learning, lead to students facing difficulties in meeting their educational needs, and result in students experiencing financial barriers that affect their educational progress. The respondents suggested that the change in family income can limit students' access to educational resources and opportunities, which can have adverse effects on their learning outcomes and well-being. The respondents to the interview schedule were asked to indicate what their experience was with regard to the effects of conflict on family income and learning. The question sought to gather insights into the experiences of educational stakeholders regarding the effects of conflict on family income and its subsequent impact on learning. The responses align in highlighting that conflicts often lead to families diverting resources away from education to meet basic needs, as observed by the Resp 1. The Resp 2 notes that families affected by conflict struggle to prioritize education due to financial constraints, directly impacting children's learning. The question of how the change in family income due to conflict affects the learning of primary school-going children is an important one, as it relates to the quality and equity of education in conflict-affected areas. The results from the Resp 1, the Resp 2, and the four Head Teachers indicate that they all share the experience of how conflicts strain family resources, sometimes resulting in students missing school or dropping out. This shared experience emphasizes that conflictrelated changes in family income pose substantial challenges to supporting children's education, reflecting the intricate interplay between socio-economic factors and learning outcomes. The respondents all pointed out how conflicts can affect family income and consequently impact children's education. The Resp 1 stated that conflicts often lead to families diverting resources away from education to meet basic needs, while the Resp 2 mentioned that families affected by conflict struggle to prioritize education due to financial constraints. The four Head Teachers also expressed similar views, noting that conflicts can strain family resources, making it challenging for students to access quality education, and sometimes resulting in students missing school or dropping out. The respondents suggested that the economic consequences of conflict often translate into difficulties for families in supporting their children's education, and reduce investments in education. The respondents highlighted the importance of addressing the socio-economic challenges faced by families in conflict-affected areas, and ensuring that children have access to quality education. The respondents were asked to suggest in what ways learning can be cushioned from the effects of conflict on family income. This sought to address the critical issue of cushioning learning from the adverse effects of conflict on family income. Several approaches are proposed to safeguard education in such circumstances. The Quality Assurance and Standards Officer suggests providing financial assistance or scholarships to affected families, ensuring that children can continue their education. The question of how the change in family income due to conflict affects the learning of primary school-going children is an important one, as it relates to the quality and equity of education in conflict-affected areas. The results from the Resp 1, the Resp 2, and the four Head Teachers indicate that they all propose various strategies to address the financial challenges faced by families in conflict-affected areas, and to ensure continued access to education for their children. The respondents all suggested different ways to provide financial assistance or support to affected families and students, aiming to create safety nets and preserve access to education, even in the face of financial challenges. The Resp 1 stated that efforts can be made to provide financial assistance or scholarships to affected families, while the Resp 2 highlighted the importance of collaborative initiatives with NGOs and government programs to offer financial support for affected students. The four Head Teachers also expressed similar views, emphasizing communitybased support systems and initiatives, flexible payment options and fee waivers, donor interventions and community partnerships, and community-driven education funds as viable strategies to assist families in need during conflict times. The respondents emphasized the importance of addressing the socioeconomic challenges faced by families in conflict-affected areas, and ensuring that children have access to quality education. The respondents were asked to indicate how family income can be secured from the effects of conflict. The question delved into the broader issue of securing family income from the disruptive effects of conflict. The responses from the RESP 1, Zonal Officer, and Head Teachers 1 and 2 focus on enhancing families' economic resilience. Suggestions include diversifying income sources, promoting income-generating activities, empowering communities with vocational skills, and facilitating livelihood support programs. Head Teachers 2 and 3 propose creating savings and credit cooperatives and strengthening local economies through entrepreneurship and job creation. These multifaceted strategies aim to help families withstand the financial shocks of conflict, ensuring their long-term income security. Additionally, HT 4 recommends education and awareness campaigns to assist families in understanding and planning for income security in conflict-prone areas, offering a comprehensive approach to address this challenging issue. The question of how the change in family income due to conflict affects the learning of primary school-going children is an important one, as it relates to the quality and equity of education in conflict-affected areas. The results from the Resp 1, the Resp 2, and the four Head Teachers indicate that they all suggest various ways to improve income security and resilience for families in conflict-affected areas, and to enhance their economic opportunities and well-being. The respondents all proposed different ways to diversify income sources and promote income-generating activities for families in conflict-affected areas, aiming to reduce their vulnerability and empower them during and after conflicts. The Resp 1 stated that diversifying income sources and promoting income-generating activities can help families become more resilient to conflictrelated shocks, while the Resp 2 highlighted the importance of empowering communities with vocational skills and economic opportunities. The four Head Teachers also expressed similar views, suggesting government and NGOs can facilitate livelihood support programs, creating savings and credit cooperatives, strengthening local economies through entrepreneurship and job creation, and education and awareness campaigns as viable strategies to improve income security and resilience for families in conflict-prone areas. The respondents emphasized the importance of addressing the socio-economic challenges faced by families in conflict-affected areas, and ensuring that they have access to quality education and economic opportunities.. --- Descriptive Statistics for Learning of Primary School-Going Children The statement reading "The school is able to implement the school curriculum effectively" has a mean score of 3.46. This indicates that, on average, respondents believe that schools in Kapedo Ward are moderately effective in implementing the curriculum. This indicates that there is room for improvement in aligning teaching methods and resources with the curriculum. This suggests a need for curriculum review and teacher training programs to enhance the effectiveness of curriculum delivery. The statement "The teachers and learners are able to complete the school syllabus in time" has a mean score of 3.67, reflecting a moderate level of agreement. The results suggest that there is reasonable progress in syllabus coverage but room for enhancing efficiency. Schools may benefit from strategies that ensure syllabus completion without rushing through topics, such as improved time management and resource allocation. The statement "The teachers are able to optimally deliver the desired lessons" scored a mean of 3.75. This indicates that teachers are generally perceived to be doing reasonably well in delivering lessons. This is a positive finding, as effective teaching is crucial for student learning. However, continuous professional development opportunities for teachers could further enhance their teaching skills. The statement "The learners continue to register high academic achievement amidst conflicts" has a mean score of 3.67. Despite the challenges posed by conflicts, learners are still achieving moderate academic success. This highlights the resilience of students in adverse circumstances. This underscores the importance of maintaining educational opportunities even in conflict-affected areas, as students can still achieve academic success. This finding highlights the remarkable resilience and determination of students in the face of adverse circumstances such as conflicts. Despite disruptions and limited resources, these learners manage to perform well academically, showcasing their commitment to education and their ability to adapt and overcome challenges. This result underscores the importance of maintaining educational opportunities even in conflict-affected areas, as it demonstrates that students can excel academically when provided with the necessary support and resources. The statement "School attendance rates registered are impressive among the learners" received a mean score of 3.46. This suggests that attendance rates are decent but could be further improved. The moderate mean score indicates that school attendance is not a major concern in the study area. It suggests that a significant portion of primary school-going children in Kapedo Ward regularly attend school. Impressive school attendance rates are essential for ensuring that children have consistent access to education, which is crucial for their academic development and future opportunities. High attendance rates can contribute to the overall quality of education and improve learning outcomes among primary school learners. Strategies to enhance attendance, such as community involvement and addressing barriers to attendance, should be explored. The statement "The environment is accommodative for learning" scored a mean of 3.54. This indicates that the learning environment in Kapedo Ward is perceived to be moderately conducive to learning, with some aspects that may need enhancement. This implies that certain conditions are in place to facilitate learning, such as adequate infrastructure, a safe and conducive atmosphere, and resources that enhance the learning experience. However, the moderate score suggests that there may still be challenges or areas where improvements can be made to create an even more supportive and enriching learning environment for primary school-going children in Kapedo Ward. In a related study conducted in Kenya's conflict-affected regions, such as parts of Turkana County and neighboring areas , similar findings were observed, where students displayed resilience and determination in their pursuit of education despite the challenges posed by conflicts. These findings align with the broader literature on education in conflict zones, emphasizing the significance of education as a means of empowerment and hope for students in such contexts . --- Qualitative Analysis The respondents were asked about their ability to adequately cover the syllabus and how they managed this challenge during conflict times. The Quality Assurance and Standards Officer acknowledged that adequately covering the syllabus can be challenging during conflicts. Schools often adjust schedules, provide catch-up sessions, or focus on essential topics to manage. According to the Resp 2, schools may prioritize core syllabus content and extend the academic calendar when necessary to ensure that students receive a comprehensive education. The Head Teachers recognized that covering the syllabus may require flexibility, additional support for students, and effective time management strategies. They also mentioned that teachers may adapt teaching methods and emphasize key concepts to ensure that students grasp essential knowledge despite time constraints caused by conflicts. Furthermore, schools employ strategies such as accelerated learning programs and supplementary materials to ensure that the syllabus is adequately covered, even in conflict-affected areas. The responses were as follows. The question of how schools and teachers manage to cover the syllabus during conflict times is an important one, as it relates to the quality and continuity of education in conflict-affected areas. The respondents generally agreed that adequately covering the syllabus can be challenging during conflict times, but schools and teachers often employ various strategies to ensure that students receive a comprehensive education. The Resp 1 stated that schools often adjust schedules, provide catch-up sessions, or focus on essential topics to manage, while the Resp 2 mentioned that schools may prioritize core syllabus content and extend the academic calendar when necessary. The four Head Teachers also expressed similar views, noting that covering the syllabus may require flexibility, additional support for students, and effective time management strategies, that teachers may adapt teaching methods and emphasize key concepts to ensure that students grasp essential knowledge despite time constraints caused by conflicts, that schools and teachers strive to deliver the curriculum by optimizing available teaching time and resources, and that schools often employ strategies such as accelerated learning programs and supplementary materials to ensure that the syllabus is adequately covered, even in conflict-affected areas. The respondents suggested that schools and teachers demonstrate resilience and innovation in delivering the syllabus, and that they require adequate support and guidance to ensure quality and equity of education. The results indicate that schools and teachers face various challenges in covering the syllabus during conflict times, such as disruptions, delays, and shortages of resources. However, the results also show that schools and teachers adopt various measures to overcome these challenges, such as adjusting the curriculum, providing extra support, and using alternative methods. The results imply that schools and teachers are committed to ensuring that students do not miss out on essential learning, and that they are willing to adapt to the changing circumstances. The results also highlight the importance of supporting schools and teachers in their efforts to cover the syllabus, and ensuring that they have access to relevant and updated curriculum materials and guidelines. The results suggest that covering the syllabus during conflict times is a complex and dynamic process that requires collaboration and coordination among various stakeholders, and that it is essential to monitor and evaluate the effectiveness and impact of the strategies employed. The question of how learners' participation in learning is affected by conflict is a relevant one, as it relates to the quality and continuity of education in conflict-affected areas. Based on the results from the Resp 1, the Resp 2, and the four Head Teachers, an analysis of their opinions was as follows. The respondents generally agreed that learners' participation in learning may decrease during conflict due to various factors, such as safety concerns, disruptions, and challenges. However, the respondents also suggested that schools and teachers work to maintain and enhance learners' participation in learning through alternative and adaptive methods, such as providing support, motivation, and continuity. The Resp 1 noted that learners' participation in learning may decrease during conflict due to safety concerns, but schools work to maintain engagement through alternative methods, such as radio or online learning. The Resp 2 emphasized that conflict can disrupt students' participation in learning, but efforts are made to adapt teaching approaches and ensure continued engagement, such as using interactive and participatory methods. The four Head Teachers also expressed similar views, mentioning that learners may exhibit reduced participation during conflicts, but schools aim to create a supportive learning environment to encourage engagement, such as providing counseling and peer support. They also noted that conflict situations can lead to fluctuations in learners' participation, but schools seek to foster a sense of continuity in the learning process, such as extending the academic calendar and providing catch-up sessions. The respondents suggested that during conflicts, students may face challenges that affect their participation, but schools strive to keep them motivated and involved in learning activities, such as celebrating achievements and providing feedback. The results indicate that learners' participation in learning is influenced by the conflict context, and that it may vary depending on the intensity and duration of the conflict. However, the results also show that schools and teachers play a vital role in ensuring that learners' participation in learning is not compromised, and that they employ various strategies to engage and support learners during conflict times. The results imply that schools and teachers are committed to providing quality and inclusive education, and that they are willing to innovate and adapt to the changing circumstances. The results also highlight the importance of supporting schools and teachers in their efforts to enhance learners' participation in learning, and ensuring that they have access to relevant and updated resources and guidelines. The results suggest that learners' participation in learning during conflict times is a complex and dynamic process that requires collaboration and coordination among various stakeholders, and that it is essential to monitor and evaluate the effectiveness and impact of the strategies employed. The question of how learner performance is affected by conflict is a relevant one, as it relates to the quality and continuity of education in conflict-affected areas. Based on the results from the Resp 1, the Resp 2, and the four Head Teachers, the analysis was as follows. The respondents generally recognized that learner performance may be affected during conflict, but they also highlighted the resilience and efforts of many students to succeed academically. The RESP 1 stated that learner performance may be affected during conflict, but many students exhibit resilience and make efforts to succeed academically, while the Resp 2 acknowledged that performance during conflict can fluctuate, but emphasized the determination and perseverance demonstrated by many learners. The four Head Teachers also expressed similar views, noting that learner performance may face challenges during conflict, but some students manage to excel despite adverse circumstances, that conflict times may pose obstacles to learner performance, but students often demonstrate adaptability and the ability to overcome adversity, that during conflict, learner performance may vary, but schools support students in achieving their academic goals to the best of their abilities, and that learner performance can be influenced by conflict-related disruptions, but some students excel through their dedication to learning. The respondents suggested that learner performance during conflict is not uniform, and that it depends on various factors, such as the intensity and duration of the conflict, the availability and quality of resources and support, and the individual characteristics and circumstances of the learners. The results indicate that learner performance is influenced by the conflict context, and that it may vary depending on the situation and the learner. However, the results also show that many learners demonstrate remarkable resilience and efforts to achieve their academic goals, and that they do not let the conflict deter them from learning. The results imply that learners are committed to pursuing their education, and that they are willing to adapt and overcome the challenges posed by the conflict. The results also highlight the importance of supporting learners in their academic endeavors, and ensuring that they have access to relevant and updated resources and guidance. The results suggest that learner performance during conflict is a complex and dynamic process that requires collaboration and coordination among various stakeholders, and that it is essential to monitor and evaluate the effectiveness and impact of the strategies employed. --- Correlations The results in Table 2 show statistically significant positive correlations between family income, and the learning outcomes of primary school-going children in Kapedo ward. All correlation coefficients are above 0.68, and the p-values are less than 0.001, indicating strong associations. Family income shows a significant positive correlation with the learning outcomes of primary school children. This implies that students from families with higher incomes tend to perform better in their studies. This finding aligns with the study conducted by Kamau and Mwangi in Kenya, which highlighted the role of socioeconomic factors, including family income, in shaping students' academic achievements. This result also aligns with the findings of Nyokabi and Karugu , who found that family income significantly influences the educational achievement of Kenyan primary school students. .000 N 24 --- Regression Analysis In this section, we present the results of the multiple regression analysis conducted to examine the relationship between various factors and their impact on the learning outcomes of primary school-going children in Kapedo ward, Turkana County, Kenya. The analysis includes three key components: the Model Summary, ANOVA , and the Coefficients table. These components provide valuable insights into the predictive power of the selected variables and their significance in influencing the learning of primary school children. The model aims to assess how factors such as school infrastructure, family income, cultural practices, and the availability of learning resources and facilities collectively contribute to explaining variations in the learning outcomes of these students. Each of these components will be discussed in detail, offering a comprehensive understanding of the findings and their implications for education in the study area. --- Model Summary The --- Analysis of Variances Table 3 presents the results of an Analysis of Variances conducted to examine the effects of access to education on the learning outcomes of primary school-going children in Kapedo ward, Turkana County, Kenya. The table provides insights into the impact of various predictors, including school infrastructure, family income, cultural practices, and the availability of learning resources and facilities, on the dependent variable, which is the learning of primary school-going children. The ANOVA results reveal a statistically significant relationship between the predictors and the learning outcomes of primary school-going children . This indicates that the combined influence of school infrastructure, family income, cultural practices, and the availability of learning resources and facilities significantly affects the children's learning. The following was the regression model: Y= β0 + β1X1+ β2X2+ β3X3+ β4X4+ ε Substituting with the values Y= -0.056 + 0.664X1+ 0.150X2+ 0.046X3+ 0.165X4+ ε The results show that availability of learning resources and facilities has . The beta coefficient for the availability of learning resources and facilities is 0.628, indicating a positive and statistically significant relationship with learning outcomes . The positive and statistically significant relationship between learning outcomes and the availability of learning resources and facilities highlights the critical role these resources play in a conflict-prone area like Kapedo. In such regions, where disruptions to education are common due to conflicts, having access to adequate learning resources and facilities can significantly enhance the educational experiences and outcomes of primary school children. This finding aligns with the local context, where improved access to resources may act as a stabilizing factor in the face of frequent disruptions, contributing to better learning outcomes. This implies that when children have access to adequate learning resources and facilities, their learning outcomes tend to improve. The beta coefficient for family income is 0.164, suggesting a positive relationship with learning outcomes, though it is not statistically significant . While the beta coefficient for family income is positive , its lack of statistical significance suggests that the influence of family income on learning outcomes may not be as pronounced as in other settings. In Kapedo, where conflicts disrupt normal life, other factors such as resource availability and safety may have a more substantial impact on learning outcomes. The positive relationship indicates that higher family income may still contribute positively to learning outcomes, but this effect is tempered by the unique challenges posed by the conflict-prone environment. The beta coefficient for cultural practices is 0.052, indicating a weak and non-significant relationship with learning outcomes . This suggests that, in this study, cultural practices do not have a substantial impact on children's learning outcomes. The weak and non-significant relationship between cultural practices and learning outcomes suggests that, in the context of Kapedo, cultural practices do not exert a significant influence on children's educational achievements. However, it is essential to delve deeper into specific cultural practices to understand their dynamics fully. In conflict-affected areas, cultural practices may undergo changes or --- ------------------------------------------------------------------114 adaptations in response to the security and social challenges faced by communities. The beta coefficient for school infrastructure is 0.178, showing a positive but non-significant relationship with learning outcomes . The positive but non-significant relationship between school infrastructure and learning outcomes implies that while improved infrastructure is beneficial, it may not be the sole determinant of learning success in Kapedo. Other factors, such as teacher quality, safety, and resource availability, may also play critical roles. Enhancing school infrastructure remains important, but it should be part of a broader strategy to improve education in conflict-prone areas.This implies that while improved school infrastructure may contribute to better learning outcomes, it is not the sole determining factor. Other variables may also influence student performance. --- CONCLUSION The study concludes that family income levels significantly affect children's education, influenced by economic instability due to conflicts, impacting resource allocation, school attendance, early marriages, and dropout rates, particularly among girls. However, family income's influence on learning outcomes may be overshadowed by factors like resource availability and safety in conflict-prone areas. --- RECOMMENDATIONS Support to programs and initiatives that address the economic challenges faced by families due to conflicts: Non-Governmental Organizations and Donors should consider supporting programs and initiatives that address the economic challenges faced by families due to conflicts in Kapedo. These programs can provide financial assistance, livelihood opportunities, and scholarships to mitigate the impact of reduced family income on children's education. This recommendation is based on the finding that family income levels significantly affect various aspects of children's education.

Access to basic education in conflict-prone communities is a significant challenge in Kenya. Empirical reviews had suggested that, during intercommunal conflicts, various factors influencing access to basic education were compromised. However, these influences manifest differently in distinct situations and locations. There has been limited research on how access to basic education was affected following intercommunal conflicts in Kapedo, Turkana County. The study aimed to examine the effect of family income levels on learning of primary school going children in Kapedo ward in Turkana County-Kenya. The study drew on three theories: Relative Deprivation theory, System Resource Theory, and Hierarchy of Needs Theory. It employed a descriptive survey research design, covering the entire population with two Ministry of Education officials, four headteachers, and twenty-four teachers as respondents. Data collection used a semi-structured questionnaire and an interview schedule, ensuring voluntary participation, confidentiality, and clarity of the study's purpose. The analysis combined descriptive statistics (frequencies, percentages, and averages) and inferential statistics (regression analysis) and presented results through charts and tables, with qualitative data analyzed thematically. The study revealed that family income affected education, with conflict-induced economic instability leading to resource allocation challenges and school attendance issues, especially for girls. The study recommends that the Ministry of Education and Local Authorities maintain the provision of essential learning resources, emphasizing administrative functionality, classroom safety, and resource access to enhance learning outcomes. Non-Governmental Organizations and Donors should support programs to address economic challenges during conflicts, offering financial assistance, livelihood opportunities, and scholarships for children's education.

The story of women's struggle for equality belongs to no single feminist nor to any one organization but to the collective efforts of all who care about human rights-Gloria Steinem On March 8, 2019, we celebrated International Women's Day, a global event that both honors the social, economic, cultural, and political achievements of women and focusses attention on the continued lack of gender balance in today's world. This movement asks that we notice the gender discrepancies present in our own spheres of influence and calls on each of us to take action to achieve a better gender balance across all facets of life. 1 Gender balance in the United States has improved through organizational efforts and the enactment of laws. The Fair Labor Standards Act of 1938, the Equal Pay Act of 1963, Title VII of the Civil Rights Act of 1964, and the Pregnancy Discrimination Act of 1973 in conjunction with unified efforts of Affirmative Action and other movements aimed at diversity and gender assimilation are a few examples that have provided substantial opportunity to minorities for education and employment opportunities in addition to protecting these individuals throughout the duration of their careers. 2 Unfortunately, despite these endeavors, statistics show that men still enjoy greater financial success and career growth. 3 It has been postulated that choices made by women are responsible for these disparities. For example, Bolotnyy and Emanuel 4 suggest that women value time away from work more than men and subsequently choose to work less overtime, take more unpaid time off, and avoid weekend/holiday shifts, which often pay more than regular work hours, all of which lead to lower pay for women. Similar claims have been made by Hutchinson et al 5 linking decreased female earnings to socially mandated family work. However, a recent study by the International Labour Organization found that, when asked whether they preferred to work in paid jobs, care for their families, or do both, a staggering 70% of women worldwide reported a preference for working in paid jobs, indicating that the male-favoring trends currently observed are unlikely to be due to any lack of desire on the part of women to succeed professionally. 6 Within the field of medicine, a similar trend has been observed. Although women constitute 50% of medical school matriculants, they represent only 39% of full-time faculty in academic medicine with an even weaker presence seen in leadership roles. 7 Female physicians are more likely to be undercompensated, are less likely to progress in academic rank, and have higher attrition rates than their male counterparts. [8][9][10] The Balance for Better campaign theme of the 2019 International Women's Day prompted a closer look at diversity within our plastic surgery specialty. 1 --- A Closer Look at the History and Presence of Women in Plastic Surgery The first known surgical practices in the world date back to 5000 BCE France when trepanation was used to treat a myriad of intracranial issues. 11 The first evidence of plastic surgery arrived centuries later with writings by the Indian surgeon Sushrata in 600 BCE. 12 Surgical texts from this era offer evidence of women playing active roles in surgery throughout Egypt, Italy, and Greece. 13 However, female presence in surgery shifted drastically in the Middle Ages with the implementation of various regulations and laws across the world, banning women from surgical and medical practices alike. 13 The return of women to medicine was an arduous journey where secrecy and disguise were required for entry into practice. Dr Miranda Stewart, the first female surgeon in Britain and Canada, concealed her true identity, dressing and practicing as a man to gain entry into medical and surgical training programs. She and Drs Elizabeth Blackwell, Emily Jennings Stowe, and Harriet Jones, to name a few, are significant historical figures, who, through their sacrifices and persistence, paved the way for the re-entry of women into medicine in North America. 13,14 It was not until 1913 that the American College of Surgeons first recognized women surgeons, and another 30 years would pass before the welcome of the first female plastic surgeon, Dr Alma Dea Morani, in 1948. 14,15 Even during her training, Dr Morani was accepted initially with observationonly privileges and was eventually afforded operating privileges only during off-hours when her male colleagues were not using the operating rooms. 14 The collective efforts of past women are now evidenced by nearly a decade of females comprising 50% of medical school graduates. 7 Of these female graduates, the majority still enter fields outside of surgical subspecialties. 15,16 In comparison to other surgical subspecialties, women are most represented in plastic surgery, and their representation has increased from 14% in 1990 to 40% in integrated plastic surgery programs in 2015. 15 Despite this substantial increase in female presence within plastic surgery training, significant gender discrepancies remain within academic postgraduate practice. Overall, 27% of plastic surgery graduates enter academic practice, and, according to the American Medical Association, women comprise only 12.3% of those within academic plastic surgery. [15][16][17] Multiple studies have demonstrated that women in academic surgery are less likely to gain tenure, hold leadership positions, or participate in research despite holding equal qualifications to their male colleagues. [15][16][17][18] Similarly, female representation among national plastic surgery associations remains low, with women constituting only 10.8% of American Board of Plastic Surgery diplomates, 10% of the American Council of Academic Plastic Surgeons, 16% of American Society of Plastic Surgeons members, and 14% of the American Society for Aesthetic Plastic Surgery . 15,16,19 In addition, women constitute a minority of invited speakers at academic plastic surgery meetings despite the impact of their published work being no different to that of men. 19 Further, recent studies have demonstrated that, when introducing academic speakers, male introducers are less likely to use formal titles in the first form of address with an even greater discrepancy of formal title use between female and male introductions, a practice that may create the perception that women are of lower status than men, despite having the same professional rank. 20 --- Barriers to Females in Plastic Surgery We currently live in an era where women become CEOs in the technological sector, presidents and founders of their own corporations, and leaders in global business. Unfortunately, although women account for 47% of the US workforce and hold almost 52% of management-level jobs, gender disparity remains present even in the business sector. [21][22][23] For example, on the 2019 Fortune 500 list, women held only 6.6% of CEO roles in all companies listed. 24 In the legal profession, women make up 45% of legal associates but only 22.7% of firm partners. 23,25 They constitute 61% of accountants and auditors, 53% of financial managers, and 37% of financial analysts, but represent only 12.5% of CFOs on the Fortune 500 list. 23,24,26 Within the US government, females now comprise a historic high of 25% of the US Senate and 23.4% of House members. 27 Interestingly, many of these women who do rise to the top of their respective professions do so by beginning in entry-level jobs within the companies they later run. Over 70% of female CEOs within Fortune 500 companies spend more than 10 years, with a median of 23 years, at that company prior to becoming CEO. 28 By comparison, the same promotional ladder for men in Fortune 500 CEO companies spans a median of 15 years prior to reaching CEO. 28 Despite these disparities, female presence in all of these professions continues to grow. How it is possible that, in this modern age, women continue to make up less than 20% of the US plastic surgery community, a community that places a great emphasis on female beauty, no less? A career in plastic surgery requires at least a decade of training and education following undergraduate studies. Not only must one make a long-term decision at, usually, a very young age, but this decision inherently entails long hours of work and study with the perception of little time for personal or social activities. For many young women in college, this path may seem daunting, especially when there remains a paucity of female role models and mentors to encourage their interests and demonstrate that a worklife balance within plastic surgery is possible. 14 Plastic surgery professional advancement during residency training and early practice years can be rigorous and grueling at a time in life when many women also seek to progress personally. Demands of work pose significant challenges should a woman wish to find a partner or spouse, and have been shown specifically to contribute to divorce amongst female surgeons. 15,18 Further, desire to start a family during biologically optimal reproductive years is not only difficult with regard to work-life balance from a practical standpoint, but also from a medical standpoint. 29,30 Specifically, the Accreditation Council for Graduate Medical Education and the American Board of Plastic Surgery offer only a 4-week maximum for maternity leave during medical training with the option for an additional 2 weeks of maternity leave that are effectively borrowed from another training year's vacation time to maintain the mandated 48 clinical weeks per year residency training requirement. This often poses difficulty for plastic surgery training programs regarding the logistics of arranging reasonable leave for new mothers and allows for very little time away from work immediately following pregnancy. For many women, this poses an incredible emotional dilemma. First, women who do choose to begin families during residency face conflicting desires with regard to spending time nourishing and cultivating a new family versus managing career and patient responsibilities. In addition, rapid return to work that is both physically and mentally demanding may limit her ability to recover from the physical and emotional aspects of pregnancy and childbirth itself. Moreover, care of a new child requires ample support from a partner or spouse, childcare, or other family members as well as financial resources. Alternatively, many women choose to postpone starting a family until after residency training or early career development. Unfortunately, for many women, this may also mean difficulty with fertility, pregnancy, and increased risk of child birth defects secondary to advanced maternal age. 29,30 Despite the long-term, long-hours commitment with time away from family that might deter surgical interest, most women surgeons are satisfied with their careers and its impact on their personal lives. 31 A recent physician survey found plastic surgeons to be more satisfied with work than doctors in any other specialty. Additionally, respondents in plastic surgery were found to have high levels of self-esteem as well as happy marriages. 32 Accordingly, one would expect continued professional growth of women in later academic practice years. However, female surgical faculty members are far more likely to be represented at lower-ranking academic levels. 33 In a 2012 report by the Association of American Medical Colleges on women in academic medicine, women surgeons represented only 5% of full professors compared with 28% of instructors, 22% of assistant professors, and 15% of associate professors. 16,34 Sasor et al 17 conducted a similar study examining male versus female distribution within professor rankings in academia and reasons for observed discrepancies. Of 206 full professors examined, only 4.4% were women. Approximately 60% of women in the study were assistant professors, whereas men were more evenly distributed among academic ranks . In this study, women were noted to be subjected to higher levels of discrimination and harassment, have lower levels of career satisfaction, and have higher rates of burnout, contributing to high rates of attrition. Similar findings have been reported in other studies linking high rates of female attrition to increasing clinical demands, dissatisfaction with work-life balance, low institutional support, and burnout. 15,17 Overcoming these challenges with successful productivity is made more difficult by smaller physical work spaces as well as a lack of academic resources, grant assistance, protected research time, and secretarial staff allocated to women. 33 Furthermore, studies have shown that, even when equal opportunities for career growth and academic achievement exist, women receive fewer awards and grants, are cited less, and have their research regarded as less valuable than that produced by men. 19,[35][36][37] These findings all contribute to what is known as the "leaky pipeline," which describes a precipitous decline in the numbers of women compared with men at each step up the academic ladder. 19,38 The aforementioned studies highlight the continual obstacles women face throughout the duration of early education in medical school and spanning into later professional years. Without reprieve from such challenges, it is not surprising that many women physicians are subject to burnout at some point in their careers. In recent years, physician burnout has been extensively examined. Numerous studies have underscored the impact of paperwork and computerization of practices; low level of respect from administration, colleagues, and staff; long work hours with poor work-life balance; lack of autonomy; and insufficient compensation as primary factors affecting burnout. 32,39,40 Interestingly, within plastic surgery, the subspecialty of aesthetic surgery has the highest burnout rate alongside microsurgery. 41 In addition to the demands of marketing, operating privately owned facilities, and the business of medicine, this is thought to be attributable to ever-increasing patient expectations of aesthetic surgery results, creating greater long-term dissatisfaction levels for patients and physicians alike. 41 The overall result in both the hospital and private sector is more demand placed on fewer providers. For most physicians, burnout peaks during midcareer, though many of those affected may not be aware of burnout until the effects have already had a significant, far-reaching impact with devastating consequences both personally and professionally. 32,[41][42][43] Physicians are historically perfectionists, with those in plastic surgery arguably being the most extreme in this regard, and they continue to place patients' needs above personal needs despite exhaustion and sleep deprivation. 44 As a result, physicians' health suffers from chronic neglect. Worse, our current culture of medicine and healthcare assigns physician wellness a low priority, with many physicians fearing repercussions when help is finally requested. 42,44 Physician burnout ultimately leads to lower job satisfaction, less productivity, less willingness to help colleagues, and higher attrition rates. 42,45 Surgical specialists have been shown to be more likely to reduce work hours or retire early as a result of burnout. 45 Given that females experience higher rates of these contributors to burnout at baseline, one might suppose that females have higher rates of burnout than their male counterparts. Although specific studies have not yet been carried out, it stands to reason that the global impact of career-long obstacles, personal sacrifice, and burnout combined have resulted in lower female representation in medicine, surgery, and plastic surgery alike. --- Evidence of Growth in Modern-Day Plastic Surgery Despite the many challenges that women have faced throughout their journey in medicine, female presence in plastic surgery is growing. Female representation has increased from 21.84% to 37.31% in both independent and integrated plastic surgery residency training programs over the last decade. 46 From 2008 to 2018, female representation in plastic surgery residency programs increased by 16.7%, second only to vascular surgery which saw an increase of 17.3% in female residents. 47 Of all surgical residency training programs in 2018, plastic surgery was the closest to approaching gender parity with a female-to-male ratio of 38.9% to 61.1%. Orthopedic surgery had the lowest percentage of female residents at only 15.3% female, although this was still a 2.9% growth in female representation compared with 2008 data. 47 On the other end of the spectrum lies obstetrics and gynecology with residency programs dominated by female representation at 82.9%. 47 It is worth noting that this finding represents the opposite form of gender disparity, which is also less than ideal. Overall, female presence is rising in all surgical residency programs, with plastic surgery most closely approaching gender parity. In addition, female residents in plastic surgery have been shown to be happy with their careers and report increasing support for simultaneous personal life progression, including pregnancy, during training. 31,48 Similarly, the percentage of females in plastic surgery academia is increasing with a nearly 10% rise in practicing female surgeons over the age of 55, indicating not only a greater number of females graduating from plastic surgery training programs but also long-term retention of active surgeons. 47 These practicing female surgeons are also increasingly taking on national roles as evidenced by an increase in societal female membership and participation. The ASPS has seen a growth of 120% in female membership since 2000. 15 The ASAPS has seen an increase to 14% female representation, up 2% from last year alone. 46 Further, female leadership in these national societies has expanded from 6.78% to 20.29% over the past decade. 46 Female plastic surgeons in training and in practice are also gaining voice and recognition within the plastic surgery literature. Although previous studies have found that women tend to publish fewer articles than men, publications by female surgical faculty authors are increasing exponentially in all areas of plastic surgery and are more likely to be cited soon after publication, suggesting higher-quality work. 15,33 Further, although women publish fewer articles than their male colleagues in early career years, scholarly productivity for female surgeons has been shown to increase over time, peaking at 15 to 30 years in practice. 15,16 These senior female plastic surgeons are generating more articles and are receiving more grants and greater overall funding than their male counterparts, suggesting that women who remain in academic plastic surgery do overcome gender disparity experienced in career infancy. 17 Thus, at all levels of career development, plastic surgery is growing in diversity and quality with continual movement towards gender parity. From medical school to residency training, from early to later career years, females continue to join the field of plastic surgery at ever-increasing rates and are demonstrating a lifelong commitment to furthering the specialty in all facets of the profession. More excitingly, this current trend is still in its infancy and will undoubtedly lead to an overall increase in female presence and leadership within our profession over the coming years. We're Not There Yet: Leadership, Mentorship, and Sponsorship --- How Can Women Compete in a Male-Dominated Field Such as Plastic Surgery? For a woman to compete in any male-dominated arena, she must first believe she can compete. That is, she must have the confidence to pursue her passion and demonstrate her competence. There is a growing body of evidence that outlines just how important confidence is for not only achieving success but simply asking for the opportunity, an attribute that most women do not adequately harness. 49,50 Women have been shown to underestimate both their abilities and performance, and routinely pass up opportunities for promotion when they perceive themselves as lacking any qualification. 49 These tendencies begin as early as grade school and, consequently, have resulted in women becoming less visible than men in many facets of life including school classrooms, conferences, and public events. 51 Worse, when women do speak up first or promote themselves, they are often seen as aggressive or bossy rather than assertive or ambitious. For women to believe they are capable of greatness, they must first be encouraged early in life. This comes not only in the form of individual support but in the presence of leaders with whom young females can identify. As such, women in plastic surgery should remember to encourage other females of all ages. Females in plastic surgery should seek not only to participate in private practice, academic, and professional society pursuits but also to attain leadership in these arenas. Female community and private plastic surgeons, board members, program directors, and senior attendings provide physical, tangible examples of role models to which young women can aspire to become. They may also provide more approachable mentors for young women to discuss professional, academic, and collaborative opportunies. 52 Secondly, women in plastic surgery must mentor other young females. Previous studies have shown that female role models are the most influential factor for female medical students interested in plastic surgery. 15 Further, women plastic surgeons are more likely than men to benefit from having a same-sex mentor in multiple areas including medicine and professional development opportunities, managerial skills, knowledge, and confidence. 16,52 These relationships foster ambition and provide younger women with the skills needed to advance in academic plastic surgery. 15 This benefit highlights the impact of underrepresentation of women in plastic surgery leadership as this inherently means fewer female mentors and may contribute to gender gaps in leadership in plastic surgery programs. 15,52 As such, it is important for private practice, community employed, and academic plastic surgeons to open their doors to young female physicians. Each of these arenas provides a different and valuable educational opportunity and perspective that may inspire a variety of interests that would otherwise go uncultivated. Lastly, and most importantly, women in plastic surgery must sponsor other women. One egregious behavior that cannot be tolerated is not offering a woman an opportunity because you think she is too busy or will not want it. 53 Sponsorship has been defined by Snyder Warwick et al as the synergistic combination of mentorship and endorsement through connections and pitches by a more experienced and networked mentor. 19 Whereas males have cultivated a long history of sponsorship among themselves, females have yet to perfect this art. 54 Female leaders in all areas of plastic surgery must take mentorship a step further and create sponsorship. We must not only invite young plastic surgery women to meetings, but ask them to speak; we must not only invite these women to sit on various organizational boards, but listen to their ideas; we must not only make them an important member of the team, but ask them to lead the team. Our accomplished female leaders in plastic surgery must help young women weave their professional webs within existing networks so that they might become a part of female camaraderie in the same manner our male counterparts have fostered among themselves. Seasoned female mentors must begin to give their ideas away to new plastic surgeons, encouraging hard work borne out of passion and celebrating success. --- What Role Do Men Play in the Plastic Surgery Gender Disparity Crisis? The role of men in the current gender disparity crisis is just as important as, perhaps in some respects even more than, that of women. Just as with women, the role of male encouragement for women begins on an individual level early in life. For fathers; for men in elementary, undergraduate, and graduate level college education; and for men in the plastic surgery community, encouraging women to simply attempt a new task or goal is key to them gaining of confidence at an early age. Studies have shown that inferior performance of women on psychological tests or puzzles is often the result of lack of attempt to even answer questions. 49,55 In these studies, sex differences were eliminated by controlling or manipulating participants' confidence. That is, when women believed they had done well on the aforementioned initial examinations, they attempted to answer more questions and matched male scoring on subsequent testing. 49,55 This illustrates an extremely important point that low confidence results in inaction. What holds women back is the choice not to try. These choices become habit at a young age for most girls. Importantly, girls who are supported by male figures in childhood are more likely to have higher self-esteem and self-confidence, graduate from college, and enter higher-paying, more demanding jobs traditionally held by males. 56 In short, positive male influence on girls at young ages is the first step to future female success. For young women to display confidence, they must be exposed to opportunities to do so. For the first female plastic surgery leaders to exist in a male-dominated profession, at least one male was required to recognize the importance and value of female presence in the field and to provide an opportunity for female participation within the profession. Without that male support and respect, the female role in plastic surgery might be very different today. As such, male mentorship and sponsorship has been instrumental in the current growth of female presence seen in today's landscape. Because plastic surgery is still largely male dominated, higher-ranking positions in private practice, academia, and national societies have been chiefly offered to and occupied by males. Although female mentorship provides young female surgeons with invaluable skillset knowledge, studies have shown that females with high-ranking male mentors report more career sponsorship precisely because of these powerful positions held by men and the opportunities they afford. 54,57 As females continue to enter the profession of plastic surgery, male mentorship and sponsorship will continue to play a vital role in furthering their career success. Continued respect and awareness of gender bias with "a carefully considerate mind" will enhance that success exponentially. 20 Along with their female colleagues, males in plastic surgery should boost female presence in our community by offering the young female surgeon encouragement in her career pursuits, opportunities to participate in larger-scale endeavors, a voice at leadership tables, and, most importantly, an example of change that supports diversity and acceptance for a more well-rounded profession. In turn, the young female plastic surgeon of today needs to seize these opportunities. Her responsibilities lie in publishing her work, presenting at symposia, speaking on the podium, promoting her work and publications through networks and on social media, and getting involved in societies and mentorship for the future generation. She should honor those who have come before her by maintaining grace and paying it forward. It is this type of environment that creates opportunities that facilitate future leadership, advance gender parity, and cultivate a sense of belonging within the plastic surgery community. 58 It is this type of environment that allows all brilliant minds to flourish. --- CONCLUSIONS International Women's Day this past year celebrated a multitude of female achievements and success. Although we have accomplished a great deal in the way of gender parity, there is still more work to be done to achieve balance within plastic surgery. Leadership, mentorship, and, most importantly, continued sponsorship are vital means by which we can achieve this worthy goal. --- Disclosures The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

The Balance for Better campaign theme of the 2019 International Women's Day prompted a closer look at diversity within the plastic surgery specialty. Gender balance in the United States has improved through many organizational efforts and enactment of laws. Unfortunately, despite these endeavors, statistics show that men still enjoy greater financial and career success. Within the field of medicine, a similar trend has been observed. Although women constitute 50% of medical school graduates, the majority still enter fields outside of surgical subspecialties. In comparison to other surgical subspecialties, women are most represented in plastic surgery. Unfortunately, significant gender discrepancies remain in postgraduate practice including academic practice rank, societal board membership, invited speaker opportunities, and compensation, to name a few. The "leaky pipeline" of women describes the precipitous decline in the numbers of women at each step up the professional ladder. We explore the multifaceted nature of this phenomenon and highlight factors that contribute to limiting female growth within the plastic surgery profession. We also emphasize the continued growth of female plastic surgeon presence in all sectors despite these existing obstacles. We submit that continued leadership, mentorship, and sponsorship provided by both male and female physicians in the field will facilitate future leadership, advance gender parity, and cultivate a sense of belonging within the plastic surgery community, allowing brilliant minds to flourish and the profession to thrive.

INTRODUCTION Suicide is a complex phenomenon that has been the object of questioning and reflection by philosophers and scholars over the centuries, with the aim of understanding this disturbing behavior. Throughout history, several perspectives have influenced the discussion on suicide, from moral and religious judgments and legal penalties to the scientific and public health approach . According to the World Health Organization , suicide is the second leading cause of death among young people aged 15 to 29, affecting 800,000 people per year worldwide . These data highlight the importance of studying suicide in health sciences and public health, in order to seek ways of prevention. Currently, suicide is understood as a multidimensional disorder resulting from the complex interaction of environmental, social, physiological, genetic and biological factors, which is defined by the behavior in which the individual, thinking about ending his life, devises a plan to kill himself. and obtains the means to do so, thus completing the act . Suicidal behavior is understood in three categories: suicidal ideation, suicide attempt and suicide itself. Self-injury does not necessarily fit into these categories, and it is not always considered suicidal behavior; since to be categorized as such, this act must be accompanied by the intention to end one's own life, that is, the simple thought of wanting to die is part of this behavior. Suicide is often an act of desperation, in which the individual does not find other possibilities of existence that can alleviate suffering or provide meaning to his life. Thus, to end this despair, one of the alternatives that the person finds is to cease with their own existence. In Western culture, the discussion of suicide has always been a taboo. The taboo, with its multifaceted meaning, is represented by a sacred, mysterious, dangerous and forbidden character, and in face of this, denotes something that must be kept at a distance. In today's society, taboos are considered funereal conduct or characteristics and subject to reproach or reclusion . Thus, filled with fears, fears and anxieties, death receives a negative connotation, which in other cultures, especially in the East, is accepted more naturally. The discussion about suicidal behavior has even more complications than death by other means, since the mysteries and violence that suicide represents can awaken helplessness, helplessness, shame, and especially guilt in survivors. Such feelings make close friends and family members of someone who died by suicide unwilling to talk about their loss, thus highlighting the taboo that society has about this phenomenon . In this context, scholars affirm the need to talk about suicide for more effective prevention, since by addressing the topic, making it more discussed, this taboo decreases. The WHO points out that this obscuring taboo reinforces a stigmatized behavior that prevents people from seeking help from health services. This way, public awareness and support for society's health systems can contribute to more effective prevention . In addition, another important measure that we can highlight for good prevention is to strengthen protective factors, such as a positive perception of life, enjoying a life project and strengthening good bonds, since the greater the affective bonds, the lower the tendency suicidal . However, erroneous beliefs about suicide perpetuate the taboo and make it difficult to provide support to people at risk. It is important to dispel these beliefs and approach the issue sensibly and honestly, strengthening the bond with the individual who suffers. In Brazil, Yellow September is a campaign started in 2015 by the Center for Valorization of Life , Federal Council of Medicine and Brazilian Association of Psychiatry , with the aim of alerting the population about suicide and its consequences. forms of prevention. This campaign brought greater visibility to the issue and became an important moment for public discussion of the phenomenon. Suicide awareness and attention are essential to deal with this problem that affects the entire world. Current research indicates that preventing suicide, while possible, involves a whole range of activities, ranging from providing the best possible conditions for raising our children and adolescents, to effectively treating mental disorders, to controlling environmental factors. of risk. Appropriate dissemination of information and awareness are essential elements for the success of suicide prevention programs . The internet plays a significant role in suicide prevention, allowing users to disseminate content related to this topic and expand the reach of the campaign. The internet has brought a wide range of information resources and services that can be easily accessed by anyone who owns it. One of the main services it offers is the high speed of communication between individuals from all over the world, as well as a way of freely expressing oneself, sharing experiences and reports about the personal experiences and feelings of users in the various social networks that it enables to form. Social networks, which serve as a "digital diary", allow horizontal and non-hierarchical relationships between participants, who can discuss different contents according to their interests and relevance . Users of these tools start to produce and share their own content, where the reader is not just a spectator, but someone who also contributes to their production. This diary is no longer like the old diary, personal and confidential, it ceases to be for intimates and becomes alterdirected. . Writing on the internet is interactive, there is a direct collaboration from the user who likes, comments, shares and criticizes. This way, this space becomes a place of jointly produced discourses. That, reflects on a perception and exchange of information in real time on various subjects, which contributes to the broadening of the discussion of the themes conveyed there, which is no different when it comes to suicide. This conversation on the network creates new perspectives, that is, subjectivities can be changed from an exchange of writings that affects both the author and the interlocutor . Suicide is a phenomenon that is presented and discussed daily in these interactive networks. Communities, pages and people create possibilities for relationships with the exchange of information, which can welcome, help and answer questions from those who address this topic. This conversation on the network creates new perspectives, that is, subjectivities can be changed from an exchange of writings that affects both the author and the interlocutor . Suicide is a phenomenon that is presented and discussed daily in these interactive networks. Communities, pages and people create possibilities for relationships with the exchange of information, which can welcome, help and answer questions from those who address this topic. This conversation on the network creates new perspectives, that is, subjectivities can be changed from an exchange of writings that affects both the author and the interlocutor . Suicide is a phenomenon that is presented and discussed daily in these interactive networks. Communities, pages and people create possibilities for relationships with the exchange of information, which can welcome, help and answer questions from those who address this topic. This new historical period we are living in, due to the ease of communication through social networks, is marked by the proliferation of narratives that yearn to be seen and heard. Our daily life is characterized by the exchange of experiences of the narratives we hear and speak, and how our experiences are told and made explicit by us and by others. . In this dynamic of creation and observation of content, the writings come to be seen as autobiographies, a text that proposes to convert experiences into words, that is, it suggests showing individual perspectives on different themes. This writing is configured as a space of self-representation, in which the subject positions himself in front of phenomena, and says about himself , and can affect others. Thus, it is interesting to look at publications on social networks to observe how certain themes are treated and how they are perceived, so that one can understand how certain phenomena appear to individuals and society. Although it is still difficult to categorically state what effects social networks have on people, it can be said that they have the potential to interfere with an individual's behavior, changing their mental health and understanding of the world. And when dealing with a subject as delicate as suicide, this is worrying and deserves attention. Bearing in mind that the publications made generally reflect the individual's perception of the phenomenon addressed, the present study is an effort to advance some productions on the general theme of death by suicide, and represents an attempt to understand the social representations of this type of death. That said, the research aims at a phenomenological analysis of the discourses about suicide in the virtual social networks Facebook and Twitter. It is expected to contribute to a discussion about this phenomenon that is so recurrent, but little discussed among people in our society. As a social being, human beings have always lived in an environment of communication and collaboration, using the technologies available in each historical phase for this relationship. Thus, one can highlight the importance of using social networks in contemporary life, especially for young people, since today, one of the main functions of these networks is to help maintain and expand human social contact, at the same time, which is also used as a great form of leisure . The internet is a revolutionary communication technology, which interferes in the lives of individuals, both in the social sphere and in the ways of thinking, acting, feeling and being, therefore, it has been appearing as an important theme for the study of psychology . This work, by proposing to analyze posts on the internet, more specifically on the social networks Facebook and Twitter, tends to obtain data on the individual's perception of suicide, consequently on how society, or a part of it, perceives this phenomenon. In addition, it may contribute to expanding discussions and reflections on this subject, offering knowledge to reduce the taboo in relation to suicide, promoting its prevention. --- METHOD The study had an exploratory nature and a qualitative approach, which sought discourses posted on the social networks "Twitter" and "Facebook" about suicide. For the analysis of the discourses, the phenomenological method was used, which focuses mainly on the phenomenological reduction to let the phenomenon show itself as it appears to the subject. In the case of the proposed study, we searched for the suicide phenomenon as it appears to the authors of the posts, and at the time of analysis, as it appears to the researcher. The intention is to stick to the attitude of returning to things themselves, free of assumptions and prejudices, seeking to understand what is shown and what appears directly to consciousness. In this sense, phenomenology intends to suspend previous beliefs and a priori explanations of a given phenomenon. . The research, regarding the material, was carried out in three stages. First, a search was performed using the Facebook and Twitter search tool for mentions of words related to suicide. For this, inclusion and exclusion criteria were established, which defined the posts considered useful to compose the sample that was analyzed. Inclusion criteria were posts written on these social networks from the years 2017, 2018 and 2019, in Portuguese, by users, pages and groups, which mention one of the words or expressions: "suicide", "suicide", "se kill", "methods of suicide", "kill me", "painless suicide", "killed himself ". And as exclusion criteria: news and images. It is notable that, when searching for the word "suicide" in the "Facebook" search tool, the following message of support is presented: "If you or someone you know is going through a difficult time, we would like to help. ", with an option to "Get support". In this option, the user is redirected to a page with three other assistance options: "Talk to a friend", which suggests sending a message or calling someone the user trusts; "Contact a support line", an option that shows three alternatives for communicating with specialized care and support services at the Centro de Valorização da Vida and, "Finding ways to help yourself ", which it refers to suggestions of things to do that other people have found useful in difficult times, such as: Ways to calm down in the middle of a crisis; a "change of scenery", which suggests going for a walk, or opening a window for fresh air; and take care of yourself, drinking a glass of water, having a meal, or looking for something to relax, like a bath or a break. To compose the analysis material, sixty posts were selected, thirty from "Facebook" and thirty from "Twitter". The first thirty posts of each social network, with the mentions identified, and considered belonging to the inclusion criteria, were copied, saved and in a file identified by numbers, corresponding to the order in which they were found. With the selected material, the second stage was the data analysis according to the phenomenological perspective. The posts of the users were read and afterwards, units of meaning were searched for in the collected texts. According to Martins and Bicudo "meaning units are discriminations that are spontaneously perceived in the subjects' descriptions when the researcher assumes a psychological attitude and the certainty that the text is an example of the researched phenomenon . In this sense, the work continued to be guided by these units of meaning, which grouped the various aspects of the subjects' experiences, what we call ideographic analysis. From these units of meaning, the nomothetic analysis began, the last part of the data analysis. At that moment, an analysis of the divergences and convergences expressed by the units of meaning is carried out, and this analysis was carried out based on an interpretation, in which the researcher evaluates what appears to him as convergent and divergent. In view of this, new categories were formed and, in a constant process of separating convergences and divergences, new, more general categories were formed. This way, the generalities formed by these analyzes, give the result of the phenomenological research, given its perspective character . --- RESULTS AND DISCUSSION Following the phenomenological method of analysis, we sought to find the units of meaning present in the individuals' speeches, which outline the understandings of the phenomenon for them. Thus, we arrived at six units that, according to our analysis, express the perspectives of the authors of the posts that made up our sample. Thus, we arrived at six units that, according to our analysis, express the perspectives of the authors of the posts that made up our sample. They are: 1) Suicide as a sin; 2) Suicide as an act of courage or cowardice; 3) Suicide as a result of depression; 4) Suicide as a resource to end unbearable pain; 5) Suicide as a failure of society;6) What to do for those who present suicidal behavior. --- SUICIDE AS A SIN It was possible to observe that a portion of the posts on the networks bring speeches that introduce elements of religious beliefs, informing that their authors relate suicide to the religious foundations they follow or believe. There are people who understand that suicide is a sin for which there is no forgiveness and this matters for the fate of the person after death, as the following posts illustrate: . In Brazil, a predominantly religious country, understanding how religions approach suicide is important, as they provide insights on this topic. The Catholic Church, throughout its history, has presented a perspective on suicide, as observed in the readings of the Old and New Testaments, as well as in speeches by influential representatives of the Church . Although ancient biblical scriptures do not explicitly condemn suicide, later dogmas, discussed in councils and in the Catechism of the Catholic Church, condemn such behavior. As the councils passed, the condemnatory perspective in relation to suicide was strengthened, establishing it as a crime associated with the demonic order, denying funeral rites and religious burial for suicides . The Catechism of the Catholic Church considers suicide as disrespect to God, since He granted free will to preserve life, not to dispose of it, since life was given by God, its creator. Each one is responsible to God for the life He has given him, God is the sovereign lord of life; we must receive it with gratitude and preserve it for his honor and the salvation of our souls. We are stewards and not owners of the life that God has entrusted to us; we cannot dispose of it . The Catechism also mentions that disorders, anguish and serious psychic suffering reduce the suicide's responsibility. Furthermore, in §2283, it states that the individual who commits suicide can receive the opportunity of repentance offered by God, not being deprived of an eternal salvation. Other religions also have positions on suicide. In Judaism, the commandments do not directly address suicide, but the Talmud condemns this action and precludes funeral rites for suicides. Similar to the Catholic Church, individual responsibility is diminished when suicide is the result of mental illness, torture, honor or chastity . In Islam, suicide is condemned, as the Qur'an states that death is decreed by Allah and cannot be anticipated. However, interpretations of some groups see certain sacrifices, such as suicides of a politicalreligious nature, as forms of heroism . In Spiritism, which is a Christian doctrine, suicide is understood as an extreme unhappiness that affects a spirit, as it is believed that the suicidal person lacks faith, in addition to being affected by a displeasure of life over these individuals. In the Spirits' Book, there is a subchapter dedicated to specific questions about suicide. There, during all inquiries, the idea is left that only God can dispose of human life, and those who end it through suicide will undergo suffering on the plane of spirits or in future incarnations. For individuals suffering from mental illness, this subchapter contains a release from guilt and punishment, because "The madman who kills himself does not know what he is doing" . From the perspective of Pentecostal evangelicals, although condemned, suicide is not directly addressed, related to this, in Brazilian evangelical churches there are forms of physical and emotional healing of the individual, rituals for liberation from demons, mental and material prosperity and resolution for various problems. Thus, various procedures are provided by the church that, in a way, can influence the approach to suicide, and according to the subjects, in a positive way . Given the above, one can observe different perspectives regarding suicide related to some religions. Its role is important, considering that it provides a system of beliefs, and also a possible protection against suicide, given that, in general, religious perspectives are condemnatory, and therefore, individuals tend to respect them. her and avoid this condemnation. However, this may contribute to an increase in the stigmatization of suicide, creating an increasingly repertoire of condemnatory and discriminatory discourses, discouraging individuals with suicidal behavior from seeking medical or psychological assistance, thus defending more religious precepts. On the other hand, the demand for specialized assistance can also be stimulated. --- SUICIDE AS A RESULT OF DEPRESSION It was common to find posts that associate suicide with depression, including in some lines this relationship is taken for granted. • So much anxiety crisis, so much depression crisis, so much desire to selfharm so much desire to kill myself, it's destroying me. Although it is not possible to predict suicide, or the possibility of asserting the cause of a suicide or suicide in general, there are factors that can aggravate your risk and make some individuals more prone to the act than others., as they are in a more fragile mental and psychological condition . A mental disorder is an almost fundamental risk factor for suicide. This occurs due to situations that tend to arise that predispose the affected individual to various stresses, such as, for example, having to adapt to the situation of the mental disorder; recurrently experiencing feelings of anxiety, anger, frustration; represent an emotional and financial "burden" for family members and close ones; and consequently, a decrease in quality of life . Depression is commonly associated with suicide, and when related to other fragile conditions, it is possible to assume an increase in this suicidal tendency. Some authors, when relating depression to suicidal behavior, consider it as a symptom or a consequence of this disorder . Depressive feelings, such as hopelessness, loss of self-esteem and the inability to face and solve problems are strongly associated with suicidal behavior . According to the World Health Organization Depression is a common disorder worldwide, and in 2018 it is estimated that more than 300 million people suffer from it. In addition to causing the affected person great psychic suffering, influencing all areas of his life, depression in the worst case can lead to suicide, according to the institution. Like most psychological phenomena, depression is a multifactorial illness. It has biological bases making heredity play an important role. People who have always lived dynamically, happily and optimistically are not exempt from the possibility of developing depression, that is, it is not just the most fragile people who can become depressed . Depression is often confused with a sadness or a natural discouragement that afflicts us during some moments of life, however, some characteristics present in both are different. The duration of depression is from weeks to months; self-esteem is usually very compromised; there is the presence of the feeling of uselessness; performance in everyday tasks is very compromised; and suicidal ideation is common. A hallmark of depression is anhedonia, a feeling that affects the ability to take pleasure in things that are usually pleasurable. Meaninglessness and feeling, a feeling of emptiness, are usually the descriptions given to feeling depressed. It is important not to neglect and be aware of these and other possible symptoms of depression, --- SUICIDE AS AN ACT OF COURAGE OR COWARDICE There are many understandings that one can have regarding a suicidal intention: from great psychic suffering, immeasurable pain, an act to draw attention, a feeling of loneliness, individual or social failure and many other reasons. Different points of view are speculated daily in discussions about suicide, and several times the question of possible courage or cowardice is introduced regarding the decision-making of the individual who chooses to die by his own hands. It is known that, given the complexity of human decisions, speculation about choices, guidelines or paths taken by subjects is a source of complex discussion, often generating controversy. • Who gave me that courage. Could it be that if we think about it constantly every day, we execute it? • Suicide act. Cowardice? In my point of view, it is not, I think you need to be very brave for such an act. Did it right who did it? From the point of view of those who made it, yes! From the point of view of the family that is in pain, no! • And who said suicide isn't the best way to break free? I admire the courage of those who got rid of this world. According to Dicio, online dictionary of the Portuguese language , courage can be defined as the ability to act despite fear, or in the face of risks and dangers, being related to bravery and courage. And cowardice is seen as a lack of courage, a gesture characterized by fear or fear. In view of this, one can introduce the dilemma, is suicide an act of courage, or of cowardice? Committing suicide can be seen as an act of extreme courage, facing the fear of the incomprehensible lack of life that death offers us. On the other hand, for others, the suicidal act can be seen as a lack of courage to face the adversities of life, characterized as cowardice. However, it must be emphasized that this dilemma is grounded in moral perspectives on suicide. That way, courage and cowardice relate to the character of the individual. He who ends his own life, considered his most precious asset, has courage. Likewise, this act can be seen as a cowardly posture, implying that the subject did not have enough strength to deal with the difficulties, and therefore chose to end his own life . Courage does not eliminate fear, but drives the individual to act even in the face of it. According to Aristotle, courage is a behavior motivated by reason, located between trust and fear, in which the person recognizes fear, but acts courageously facing it . On the other hand, Michel Foucault approaches courage related to suicide within the perspective of a biopolitical society, which values life at any cost, promoting the search for eternal youth and health. In an existentialist perspective, having courage is being able to obtain possibilities for self-realization even taking into consideration, an anguish that threatens one's own being, and having the strength to assume this goal and transform this anguish into ways of coping for the individual. However, the individual, due to the human condition itself, is never free of this feeling of anguish, and is always subject to its reappearance, thus, courage is essential to overcome anguish, since this condition is inherent to human existence. Forghieri says about the individual who has overcome the anguish: "This way, he recovers the psychological balance, which will be, again, risky to be, again, conquered, and so on in the course of his existence". Within this perspective, in relation to the discussion of suicide, a question must be asked: is suicide a confrontation with anguish or an escape from it? Authors refer to suicide as one or the last possibility that the individual found to end the great psychic suffering that afflicts him. Faced with this, courage starts from the principle of overcoming distressing states to a state of balance, so that the individual can then move on to the next overcoming. However, when there is suicide, there will be no possibility of trying to reestablish psychic balance, due to the extinction of the being itself. That said, from this perspective, the suicide does not correspond to this conception of courage, as he does not welcome the threatening anguish, but, because he has nowhere else to go, he runs away from it. If we take Tillich's conception of courage, we will see that contrary to what is thought in relation to suicide, courage is related to the affirmation of being, and it is decisive for human beings to remain as beings in the world. For this author, courage considers taking upon oneself the problem of anxiety, fate and death, as they are inherent to the human condition, and involves three dimensions: "the courage to accept the world that surrounds us, the courage of solitude and the courage to participate in the creative power that is in every person" . --- SUICIDE AS A RESOURCE TO END UNBEARABLE PAIN The suicidal act is not something casual or without purpose, on the contrary, it refers to the attempt to resolve a situation that is causing intense suffering to the individual. This is a suffering that involves feelings of hopelessness and helplessness, which regularly arouse conflicts between the survival of the being and an unbearable exhaustion, in which the perceived options for solving problems are shortened and, thus, the need to escape is shown, through death, in the face of this torturous affliction . • When a person thinks about suicide, understand, he wants to kill the pain and not life... when he reaches the point of killing himself, it's because he was already dead and nobody noticed. Brazil is the country in Latin America that is in 1st place in the depression index... until when are we going to close our eyes? • Then you imagine how a person is feeling when they think about suicide! In his head there is no more solution for him. The soul hurts! The worst thing that exists is that you live without meaning. For what? Where? Do what? With whom? It will be? As? And the days go by, and nothing changes! You don't eat, you don't sleep, your body shakes, you cry all day, a hole in your chest insists on not going away, an anguish, a total disappointment, it hurts, it hurts a lot, and how it hurts!!! • Those who attempt suicide actually don't want to kill themselves, they want to kill the pain that exists inside them. Let's help each other more, pay more attention to each other... Throughout human life, it is common to experience experiences that arouse different types of emotions, which can favor states of satisfaction, euphoria, sadness, as well as extremely unpleasant emotions, considered deep and destructive. These uncomfortable feelings constitute pain distinct from physical pain, and are focused on a psychological dimension of pain, as named by Shneidman . This intolerable internal pain is associated with an introspective experience of negative emotions, linked to sadness, fear, anger, anguish, despair and loneliness. And it justifies the cause of this pain, arising from frustrations of basic psychological needs, such as the needs for achievement, autonomy, recognition, the failure to materialize important interpersonal relationships and even difficulties in dealing with suffering . Different perspectives and theoretical models address psychological pain, but there is a consensus that it is an intolerable, unsustainable and extremely unpleasant pain. It is seen as a rupture in individual and social integrity, resulting from the disappointment and despair caused by the non-fulfillment of goals and expectations. In cases of depressive episodes, psychological pain can be perceived as worse than any physical pain ever experienced . Shneidman highlights the relationship between psychological pain and the risk of suicide, stating that this pain may be a necessary factor for suicide to occur. When negative emotions exceed the individual's tolerance limit, he may consider suicide as the only alternative to end this pain, especially when the possibilities of life seem null or extremely reduced. Faced with the recognition of psychic suffering as an important factor in suicidal behavior, it is essential to reflect on forms of support for the suicidal subject, taking into consideration, the way of dealing with this pain, in order to reduce the risk of suicide. It is essential to understand that, during a suicidal crisis, the individual's psychological state can prevent the search for solutions to their problems, highlighting the importance of considering this pain and adopting a humanized approach towards the subject. Some looks at suicide demonstrate disregard for those who are suffering, which devalues their feelings and can increase the feeling of hopelessness for the suicidal subject. --- SUICIDE AS A FAILURE OF SOCIETY In most of the questions present in the posts about the reasons for a suicidal act, the targets are the individuals who practice it, that is, the explanations fall on psychic suffering , an act of courage or cowardice, lack of sociability, loss of something fundamental to life, etc., reducing the explanation to factors centered on the individual. In the 1960s, the UN classified suicidal behavior as a multifactorial, multidetermined phenomenon that develops along complex and identifiable paths. Given this, an important aspect can be noted that must be addressed so that we can have a broader understanding of these possible multiple determinations, which is the question of the role of society and the social problems that surround this phenomenon. . There are users of social networks who perceive a connection between certain social conditions and suicide. In the posts that were analyzed in this study, one appeared that puts someone's suicide as a result of society's failure. Durkheim, a renowned sociologist, approached suicide as a social phenomenon, distancing himself from an individual psychological perspective. He argued that suicides must not be analyzed in isolation, but as a whole, since they constitute a new social fact with its own nature. Durkheim believed that these social facts already exist in society even before the birth of individuals, and they affect all spheres and participants . Indeed, if, instead of just seeing suicides as particular events, isolated from each other and which demand to be examined separately, we consider the set of suicides committed in a given society, during a given unit of time, it appears that the total thus obtained is not a simple sum of independent units, a collection whole, but that it constitutes in itself a new and sui generis fact, which has its unity and its individuality, consequently its own nature, and which, moreover, it is an eminently social nature. Durkheim's proposal was to study suicide through the understanding of social facts and collective consciousness, which consists of beliefs and feelings shared by most members of a society. To understand the phenomenon of suicide, Durkheim emphasized the need to understand the social causes that lead to suicidal predisposition and these collective phenomena . Durkheim identified social cohesion as an essential element and argued that the greater the social cohesion, the lower the suicide rate in that population. He illustrated this by comparing suicide rates in societies with different predominant religions. In societies with a predominant Catholic religion, suicide rates are lower compared to societies where Protestantism is predominant. This is due to the principle of free examination that characterizes Protestantism, allowing more individual thinking and less group integration, in contrast to Catholicism, which has rigid traditions and greater group integration. The dissolution of institutions that promote the integration of individuals, such as religion, family and the State, can affect suicide rates in society. The lack of support in forming sets of shared ideals, or "collective consciousness", that give meaning to life, contributes to a feeling of excessive individualism and low social cohesion, leaving peoplepeople more vulnerable to suicidal behavior . On the other hand, Michel Foucault proposed an analysis of modern society as a biopolitical society, where life is considered the most valuable asset and must be preserved . This perspective is rooted in a capitalist model of production, in which bodies are disciplined and regulated to become productive. In this context, the suicidal act is considered a pathology and prevention policies are created to keep bodies useful and docile to society . However, this emphasis on preserving life intensifies the individual's suffering and reflects the disease of modern man. Marx , in turn, considers that social injustice, unemployment, misery and violence fostered by capitalist society are the conditions for suicide. And he recognizes that "although poverty is the greatest cause of suicide, we find it in all classes, both among the idle rich and among artists and politicians" , because capitalist society dehumanizes everyone. --- WHAT TO DO FOR THOSE WITH SUICIDAL BEHAVIOR When performing the analysis of the collected posts, it was noticed the presence of information about possibilities of support for the individual with suicidal behavior. This way, it was possible to observe that some of these posts pay attention to considerations on what to do in this situation. Preventive actions are considered essential to alleviate the problem of suicide, as highlighted by the WHO . Several activities aim to improve therapeutic methods and address the environmental and mental health risk factors associated with this phenomenon. The dissemination of adequate information and awareness of the population are essential elements to strengthen prevention programs . In addition, identifying risk and protective factors is crucial to reducing the risk of suicide. The WHO includes family and social support, religious and cultural beliefs, community involvement, satisfactory social life and access to mental health services as protective factors. Knowledge about suicidal behavior has advanced, revealing the importance of the interaction between several factors in determining these behaviors. Epidemiology has contributed to identifying risk and protective factors, in addition to highlighting the cultural influence in this context . The media plays an important role in suicide prevention, and the WHO offers a handbook for professionals in this area, providing guidelines to adequately address the topic. Some productions, such as the "13 Reasons Why" series, have adopted WHO recommendations, including alerts and resources to seek help . In Brazil, the recognition of suicide as a public health problem resulted in the publication of national guidelines by the Ministry of Health in 2006, aiming to guide a National Suicide Prevention Plan. This plan seeks to develop strategies to promote quality of life, inform society, promote care and intervention projects, and promote the education of health professionals . Another initiative of the Ministry of Health is the creation of a Suicide Prevention Manual for mental health teams, which aims to guide professionals in the treatment of people with suicidal behavior and contribute to reducing the taboo around this topic . The Ministry of Health also provides recommendations for dealing with a person with suicidal behavior, including recognizing the warning signs, having a sincere and calm conversation, encouraging the search for professional help and maintaining contact in times of crisis . --- CONCLUSION The purpose of this study was to unravel the understandings of suicide from narratives or reports shared on the social networks Facebook and Twitter. These media provide a space where people can speak freely about their understanding of various phenomena, including suicide. To achieve this goal, we consider it important to address the issue of suicide by observing and describing the perceptions expressed by others, without prejudice or taboos, and without seeking causal relationships in advance. Our goal was to understand how people turn to this phenomenon. We found that the internet, as a means of online communication, facilitates access to content about suicide, providing information about methods, encouragement and possibilities. At the same time, we noticed that the internet also promotes preventive communication, through campaigns, online support groups, websites and blogs, which aim to prevent suicide. Thus, the possibility of using the virtual network as a prevention strategy is evident, training professionals to provide support both in person and through chats, groups and forums. We were surprised by the richness of the material collected and how the internet, this "new" area of study, can increase knowledge and understanding about suicide. The analyzed reports revealed a multiplicity of aspects related to the theme, which can be substantiated by the historical roots surrounding this type of death. When researching conceptions about suicide, we found the prejudices that stigmatize this phenomenon and the ideas that surround it, based on taboos and historically grounded beliefs. We observed that users' perceptions regarding suicide are diverse and reflect the notion that suicide is a multidimensional and multidetermined phenomenon. Aspects of a religious nature, rooted in the Middle Ages, and aspects related to contemporary scientific knowledge, such as studies on psychopathology and, especially, depression, are striking in users' perceptions. It is important to take these different aspects into account in suicide prevention, working on the nuances of individuals' subjectivities and recognizing the difficulties in understanding the scientific knowledge on the subject. The subjects' speeches reveal different interpretations of the human experience in the face of suicide, demonstrating the plurality of voices present. Some see suicide as society's failure to support individuals, while others ground it in religious concepts. There are also those who no longer see life as a possibility in the face of suffering, as well as those who consider the courage to dispose of life as a valuable act. The theme of suicide allows a wide range of meanings, requiring an approach that does not reduce these understandings in a simplistic way. In this work, we seek to signal suicide as a Public Health problem and recognize the dimension of this phenomenon. The World Health Organization has wellestablished research on preventing this type of death. Our objective was to contribute to a plural discussion, providing a reading that would clarify understandings about suicide and cooperate in the development of additional prevention strategies. In addition, we found that part of the users' reports is related to scientific conceptions about suicide. This helps these people understand the risk factors and possibilities for support for individuals with suicidal behavior. Therefore, we highlight the importance of talking about suicide in order to break with the taboos that surround it. We noticed that the apprehension or fear of approaching this subject reveals a general lack of information. As long as the taboo persists, perceptions that the topic must be silenced will be reinforced. However, our finding is that talking about suicide contributes to more effective prevention and demonstrates empathy towards the suffering of others. This way, we can give voice to the pain and, consequently, offer support to the suicidal individual.

Throughout history, the phenomenon of suicide has been discussed and questioned from various perspectives that contributed to the formation of multiple conceptions about the theme. Currently, from a scientific point of view, this phenomenon is seen as a scientific problem, and also a public health problem. The Internet today has brought an extensive range of information resources and services that can be easily accessed by those who have it. It provides a platform that enables people to express themselves freely, sharing experiences and reports about personal experiences and feelings in the various social networks that it allows them to form. Among the themes addressed on these networks is suicide. The present study aimed to perform a phenomenological analysis of the discourses about suicide on virtual social networks, considering that the publications made generally reflect the individual's perception about the phenomenon addressed. The research is exploratory in nature and qualitative in approach, and sought the discourses about suicide in the social networks Twitter and Facebook. From the data analysis, meaning units that relate suicide around themes such as religion, courage and cowardice, depression, failure of society, unbearable pain, and the need for support to individuals with suicidal behavior emerged. In this communication, we intend to present the results of this study, which shows how people in general understand suicide.

Introduction Suicide is a leading cause of death in young people in the 15-to 29-years age bracket worldwide [1]. A recent meta-analysis of 634,662 students by Mortier et al. [2] found that the pooled prevalence of lifetime suicidal ideation and suicide attempts were 22.3% and 3.2%, respectively. In China, a study by Yang and colleagues [3] indicated that the pooled prevalence of lifetime suicide attempts among 88,225 college students was 2.8%, with the highest rates recorded among rural students . The risk of lifetime suicidal ideation and suicide attempts among college students was higher than adults' prevalence rates worldwide [4]. Religion and religiosity have been proposed to be protective factors for suicide since Emile Durkheim's study, which revealed that Protestants reported higher suicide rates than Catholics in late 20 th century Western Europe [5]. The connection between religion and emotional wellbeing has spurred numerous empirical studies over the past 50 years to understand further the complex relationships between religion and suicidality [6]. Religious affiliation, commitment, and practice are among the few independent factors reported to contribute substantially to lower the likelihood of individual suicidality [7,8]. Religion has also been related to the country and regional suicide rates [9,10], with most studies focusing on Western countries. In a cross-national study of 22 European countries, the results suggested that religion is a protective factor in the relatively secularized European nations and regions after controlling for economic level, economic strain, and education [11]. A study on 124 countries using the WHO data on suicide rates indicated that Islamic countries had significantly lower suicide rates than non-Islamic countries [12]. A meta-analysis on religion and completed suicide also showed that religion serves as a protective factor in Western countries but loses its protectiveness in Eastern countries [13]. A number of studies on religious affiliation and suicide among university students have revealed inconsistent findings. For example, a study in Australia found that a greater proportion of students affiliated to Protestantism and Catholicism reported experiencing suicidal ideation compared to the group with no religion. However, the no-religion group had a larger proportion of individuals who had attempted suicide [14]. Among Ukrainian college students, those with a religious affiliation had a lower likelihood of reporting lifetime suicide attempts compared to individuals with no religion [15]. In terms of inter-religion differences, a large-scale study on LGBQ university students found that Jewish-affiliated participants were less likely to report lifetime suicidal ideation, but non-religious participants were more likely to wish they were dead compared to Christian LGBQ participants [16]. Eskin et al.'s [17] study of university students across 12 countries showed that Muslims had a higher risk of attempting suicide while Buddhists, Catholics, and individuals with no religion had lower risks. These findings indicate that the association between religious affiliation and suicidality is an important area for further investigation, especially in non-Western settings such as China. In China, only an estimated 15% of the population report a religious affiliation [18]. Studies examining associations between religion and suicide have gained momentum, although existing studies indicated mixed findings. For example, the age-standardized rate of lifetime suicidal ideation and lifetime suicide planning was significantly higher in the mostly Muslim Hui ethnic group than in the mainly atheist Han ethnic group [19]. Similarly, Zhang et al. [20] found that religious believers reported higher depression and suicidal ideation, suggesting that religion may be a risk factor for suicide. Lew et al. [21] and He et al. [22] found that religion may be a protective factor in their study of college students in Shandong and Northwestern China. Wang et al. [23], however, found no significant correlations between religious involvement and suicidal ideation, plan, and/or attempt in either Muslims or those not following any religion. We have chosen to measure the type of religious affiliation as a risk/protective factor for suicidal thoughts and behaviors due to a few reasons. First, doctrinal beliefs regarding suicide vary between different religious beliefs and may influence suicidal behavior. For example, devotees of Christianity and Islam believe that suicide is a sin, and therefore a doctrinal commitment to these religions may serve as a suicide deterrent [24]. Compared to other religions, Muslims have the lowest level of permissiveness towards suicide [25]. In contrast, it has been found that Hindus and Buddhists hold more permissive views of suicide [26]. As past studies have indicated a positive relationship between attitudes toward suicide and suicidality, an individual who is affiliated with Islam may have different levels of suicidality compared to an individual who is affiliated with Hinduism or Buddhism. Secondly, the association between religious affiliation and suicidality needs to be examined against the background of the predominant culture of a locality. Eskin et al. [17] proposed that religiosity may lose its protectiveness in a culture where religious affiliation is compulsory or is normative. On the other hand, according to Hu et al. [27], the protectiveness of a religion against psychological distress depends on the social status of the religion. In their study, Christians were found to exhibit worse depression symptoms compared to Buddhists and individuals with no religion. This led them to hypothesize that self-identification with a marginalized religion may be a psychological burden [27]. Therefore, we aim to examine whether different religious affiliations among college students in China are associated with overall suicidal behavior, suicide attempt, and suicide risk. For this study, religious affiliation is defined as the self-reported identification as belonging to a specific religious denomination . --- Materials and methods --- Study design We conducted a large cross-sectional cluster sampled study of undergraduate college students in six provinces in China. --- Data collection Data were collected in a paper-based survey format from students enrolled in various undergraduate degrees from six provinces between October 2017 and March 2018: Ningxia, Shandong, Shanghai, Jilin, Qinghai, and Shaanxi. Ethics approval was obtained from the School of Public Health ethics committee, Shandong University . One university was selected in each province through convenience sampling. Students from each department were clustered according to the year of study. An equal number of classes from each year of study were then selected to obtain a reasonable representation of each grade. All students in the selected classes were briefed about the research. To be eligible for participation in this study, an individual had to be at least 18 years of age and enrolled as a student from one of the six participating undergraduate programs. Participants completed the questionnaire anonymously in about half an hour, and no personal identifiers were collected. Participants were given a small gift equivalent to $1 in value upon completion of the questionnaire. All participants provided written informed consent. Hotlines on counseling services were provided in the information sheet tailored to each province. --- Questionnaire Demographics. The following information was collected: age, gender, year of study, and religious denomination . No free text response field was provided to describe what 'other' religion participants were. Suicidal Behaviors Questionnaire-Revised . The SBQ-R was developed as a brief measure of a range of suicide-related behaviors for use in both clinical and non-clinical settings. It is a 4-item self-report questionnaire [28]. The total score ranges from 3 to 18, with higher scores indicating a greater risk of suicidal thoughts and behaviors. This study uses a cut-off score of � 7 to indicate suicide risk, based on the recommended cut-off score for undergraduate students by Osman et al.'s [28] validation study of the SBQ-R. As in studies in clinical and non-clinical settings, we used the SBQ-R Item 1 to determine lifetime suicide attempts: "Have you ever thought about or attempted to kill yourself?". Participants who chose response options, "I have attempted to kill myself, but did not want to die" or "I have attempted to kill myself, and really hoped to die," were identified as the lifetime suicide attempt participants. The Chinese translated version yielded internal consistency reliability of Cronbach's α = 0.67 for the SBQ-R total scale score [29]. In this study, the Cronbach's α of the scale score was 0.75 for the study samples. Beck Hopelessness Scale. The Beck Hopelessness Scale was developed by Beck and colleagues [30] to measure three dimensions of the hopelessness construct: feelings about the future, motivation loss, and expectations. It is a 20-item questionnaire, ranging from 1 = "in full compliance with" to 5 = "completely opposite of" the stated item. The total scale score is usually derived to evaluate levels of the hopelessness construct; higher total scores represent higher levels of hopelessness. The estimate of internal consistency reliability is high in a population of suicide attempters [30]. Scores derived from the scale are positively correlated with scores on measures of suicidality [31]. Yuan et al.'s [32] study among Chinese university students revealed the internal consistency reliability of Cronbach's α = 0.90. In this study, the Cronbach's α of the scale score was 0.80 for the study samples. Psychache Scale. The Psychache Scale [33] consists of 13 items reflecting psychache scored from 1 = "never or strongly disagree" to 5 = "always or strongly agree." The Psychache Scale scores have shown acceptable psychometric properties, with alpha reliability coefficients of 0.90 and higher when completed by university students [33]. In a sample of Chinese students, Cronbach's α was 0.96 [34]. In this study, the Cronbach's α of the scale score was 0.96 for the study samples. DASS-21 depression subscale. DASS-21 is a well-established instrument comprising three psychological distress dimensions, including depression, anxiety, and stress [35]. Each dimension is composed of seven items. The score on each item ranges from 0 = "did not apply to me at all" to 3 = "applied to me very much," or "most of the time"). The total scale score ranges from 0 to 63. Sub-scale scores can also be used to measure each dimension, which ranges from 0 to 21. The DASS-21 has been widely used in China for various psychosocial studies, such as Cheng et al. [36], which reported internal consistency reliability of Cronbach's α = 0.77. For this study, we used the depression sub-scale score in the analysis. The Cronbach's α of the sub-scale score was 0.88 for the study samples. Self-esteem scale. The self-esteem scale , developed by Rosenberg [37], was originally used to assess adolescents' overall feelings of self-worth and self-acceptance. The SES is currently the most widely used self-esteem measure of this construct and has an acceptable estimate of internal consistency reliability . Although commonly used with adolescents, the scale has also been used in a Chinese college student sample [38]. The SES consists of 10 items, with scaling ranging from 1 = "strongly disagree" to 4 = "strongly agree." The total scale score ranges from 10 to 40. Higher scores indicate more significant levels of self-esteem. The Chinese SES was tested in China and had an acceptable estimate of internal consistency reliability [38]. In this study, the Cronbach's α of the scale score is 0.65 for the study samples. Social support. The 12-item Multidimensional Scale of Perceived Social Support was used to measure social support. Each item is scored using a 7-point Likert-type scale ranging from 1 = "very strongly disagree" to 7 = "very strongly agree," resulting in a total score range from 12 to 84 [39]. The scale has acceptable reliability and validity estimates in the Chinese context [40,41]. The MSPSS measures social support from three social support sources, including family members, friends, or significant others . Higher scores on this scale suggest a higher level of social support [39]. The total score is used to assess the overall total support from the three identified sources. In this study, the Cronbach's α of the scale score was 0.94 for the study samples. Purpose in life. The four-item purpose in life test-short form was used to measure the extent to which participants felt their lives had meaning and purpose [42]. The PLT-SF includes a 7-point Likert-type scale response format. Responses to the items are summed to obtain a total scale score ranging from 4 to 28. Higher scores suggest greater perceived meaning/purpose in life. A Chinese version of the PLT-SF has been shown to have an acceptable internal consistency reliability estimate [43]. In this study, the Cronbach's α of the scale score was 0.92 for the study samples. --- Statistical analysis Univariate and multivariate statistical analyses were conducted using the IBM SPSS v.21 . The participant demographics were computed using descriptive statistics. Chi-square tests were used to examine the associations between type of religion and suicide risk and suicide attempt. We used a series of one-way analyses of variance to examine mean group differences between participants who reported "not following a religion" and those who identified a specific religious affiliation on the study selfreport measures. These were scores for risk and protective measures. We extended the analyses by conducting a multiple regression analysis to assess the impact of religious affiliation on suicidality, adjusting for demographic factors , province, and psychological distress factors as covariates. Specifically, the SBQ-R total score was used in the analysis to measure suicidal thoughts and behavior. All potential continuous predictors were mean-centered before they were included in the analyses. A multiple logistic regression analysis was conducted to measure the odds of being at risk for suicide for participants from each religious affiliation. Using the recommended total SBQ-R cut-off score of 7 or higher, 1,801 participants met the criteria for suicide risk ; those with scores below this cut-off were assigned to the control or reference group . These analyses included all the study participants . Participants' age, gender, province, and scores on the risk and protective self-report measures were covariates in the analysis. Finally, unlike the previous analyses, the subsequent analysis used scores on the SBQ-R Item 1 . A total of 216 participants reported a lifetime suicide attempt ; those who did not report a lifetime suicide attempt were assigned to the control or reference group . These analyses included all the study participants . A multiple logistic regression analysis was conducted to measure the odds of a lifetime of suicide attempt for participants from each religious affiliation. Participants' age, gender, province, and scores on the risk and protective self-report measures were covariates in the analysis. For all comparisons, differences were determined using two-tailed tests, while p-values less than 0.05 were considered statistically significant. Missing data were deleted list-wise during the statistical analysis. --- Results --- Demographics A total of 11,407 college students from universities in the six Chinese provinces of Ningxia, Shandong, Shanghai, Jilin, Qinghai, and Shaanxi participated in this study. Cases with missing data, including gender, age, or any item of the SBQ-R instruments and religious denomination, were not included. In total, 9,602 responses were analyzed . Of these, there were 33.0%, 33.5%, and 31.4% participants in their first, second, and third years of college or above, respectively. Most participants reported no affiliation with any particular religion . The type of religion varied significantly between provinces = 3348.09, p<0.001), with Shandong participants reporting the highest percentage of having no religion compared to the lowest in Qinghai . Ningxia had the highest number of Muslims , Shaanxi the highest number of Christians , and Qinghai the highest number of Buddhists/Daoists . In terms of gender breakdown by religion, 29.6% out of 5,746 females and 27.7% out of 3,856 males reported a religious affiliation. --- Suicidality by religion Suicidality which was measured using the SBQ-R total score, was the highest in the Shanghai province and lowest in the Shandong province . Similarly, the percentage of participants reporting suicide risk was the highest in Shanghai province and the lowest in Shandong province , χ 2 = 121.41, p<0.001 . Christians reported significantly higher suicidality score compared to those affiliated with Buddhism/Daoism , other religions , individuals reporting not following a religion , and Islam . At the same time, Muslims had lower levels of suicidality than Buddhists/Daoists and those with no religion, F = 17.82, p < 0.001, η 2 = 0.007. Similarly, a higher percentage of Christians were at risk of suicide = 39.34, p < .001) and had attempted suicide (7.5%; χ 2 = 48.95, p<0.001) . --- Religion and risk/protective factors for suicidality Results of the one-way ANOVAs indicated that risk factors for suicide such as the level of hopelessness were significantly higher among all religions compared to those with no religion, except for Islam . The results of the multiple linear regression suggested that, after adjusting for age, gender, province, hopelessness, depression, psychache, self-esteem, social support, and purpose in life, those with a Christian religious affiliation reported higher suicidality levels , whereas Muslims had lower suicidality levels . Together, the independent variables accounted for 19.2% of the variance, R 2 = 0.192, adjusted R 2 = 0.190, F = 126.43, p<0.001 . A multiple logistic regression analysis was conducted with suicide risk as the dependent. The full model was statistically significant, = 1344.68, p<0.001). This model accounted for 22.2% of the variance in suicide risk . Together, the model correctly identified 81.7% of the participants with suicide risk. The results indicated that participants affiliated with a Christian denomination had 1.5 times higher odds of having an elevated suicide risk . Another multiple logistic regression analysis was conducted with lifetime suicide attempts as the dependent. The full model was statistically significant, = 218.36, p<0.001). This model accounted for 12.6% of the variance in suicide attempts . Together, the model correctly identified 97.8% of the participants with suicide attempts. The results indicated that Christian participants had 3.1-times higher odds of reporting a previous suicide attempt . --- Discussion Our key finding suggests that religious denomination may be either a risk or a protective factor for suicidality. It should be noted, however, that suicide risk per se was low amongst this sample. Specifically, being of the Christian faith appeared to be associated with increased suicidality, suicide risk, and suicide attempt. These results are not consistent with past findings among college students in Western countries, where affiliation to Catholic and Protestant Christianity was protective against suicidality [14], and those who professed a religious affiliation were less likely to have attempted suicide [15]. Compared to other religions, being of Christian faith appeared to be associated with higher levels of hopelessness, psychache, and depression, as well as lower levels of self-esteem, social support, and purpose in life, all of which are known risk and protective factors for suicidality. The higher depression level among the Christian participants is comparable to the findings of a study by Hu et al. [27], where it was also found that Christians in China's general population were more likely to be depressed compared to Buddhists and atheists. Other studies in China have also revealed that increased depression and hopelessness, and decreased social capital were predictive of increased suicidality [44,45]. Taking these findings into consideration, the greater suicide risk among the Christian participants in our study could originate from their worse psychological health. This may be because adherence to the Christian faith places an individual in a minority group in China, as the Christian population in China is small and loosely spread across China [46]. For example, in this sample, most Christians were Han Chinese, which made them a minority compared to the majority of Han Chinese who did not profess any religious affiliation . Also, Christians reported the lowest level of social support in this sample, indicating feelings of exclusion. In contrast, being Muslim was found to be protective against suicidality, given the lowest scores in hopelessness. Unlike Christians, who are a minority within their nation and race, Muslims are a majority within the Hui race in this sample . Even though Islam is not the majority religion in China, the concentration of Muslims in Northwestern China is high [46]. The role of religion as a protective or risk factor for suicidality may be explained by Rodney Stark's moral community hypothesis, which postulates that the aggregate level of religiousness in a group will affect the attitudes and behaviours of its members, whether or not they are affiliated with a religion � p < .05; �� p < .01; ��� p < .001. Depression is measured using DASS-21 Depression sub-scale. Dunnett post-hoc analyses were conducted using "Not following a religion" as the reference group. https://doi.org/10.1371/journal.pone.0251698.t002 [47]. The moral community hypothesis found mixed support in a study on Chinese college students, where provinces that had a higher number of mosques were associated with lower odds of deviant behaviour, but the relationship was not significant where Christianity and Buddhism were examined [46]. Similarly, in a community or province with higher religiousness, the likelihood of religion being a protective factor against suicidality will be higher. The finding also means a country or community with low religious rates, such as China may have lower religiosity, and this may lead to religion having a lower or no protective effect against suicidality. This hypothesis, however, remains tentative and requires further evaluation in the future. However, given the low rate of religious affiliation in China, and also its repressive political and social policy towards religion [18], another alternative hypothesis we propose is the "religious minority hypothesis". This hypothesis can characterize an environment where religious affiliation is low in the community, province, and nation, and the practice of religion is reported to be tightly controlled by the government. China, a communist country, has the largest population in the world, with 1.4 billion people, but it has the world's lowest religion rate estimated to be about 15% [18]. The Chinese government has been reported to restrict the practice of religion and does not include religious elements into its public policy and decisionmaking processes [18]. Religious freedom is actively managed/controlled. In such an environment, it may be detrimental or even stressful to profess too strongly in a religious belief and/or to practice religion openly. This may be a root cause leading to a sense of discrimination, decreased social integration and connectivity, low belongingness to the society they interact with, disturbance in family harmony, social isolation, and clashes in value systems and aspirations. The restrictions imposed may have led to religion losing its protective effect against suicidality, and in our sample, Christians and Buddhists/Daoists even reported higher levels of suicidality and/or risk factors. Thus, the religious minority hypothesis may help to explain why certain religions are not protective against suicidality. Islamic adherents, however, are more likely to form close social support networks, offering a stronger sense of community and cohesion [47], which could serve as a protective factor, thus lowering suicide risk and negating other negative psychological factors. However, as stated in the moral community hypothesis, there is a potential for these suicidal risks to be stemming from regional differences, which is also tied to the religious demographics of the region. Therefore, this hypothesis should be subjected to further research. The study has a number of limitations. First, with the cross-sectional design, inferences of causation cannot be drawn. Second, this study is limited to undergraduate students in urban provinces we sampled and is not generalizable to all universities in China. The religion rate reported in our study should not be assumed to represent the religion rate of any particular province or the general population in China. In addition, we did not measure the strength of the participants' religious affiliation. A number of factors which has been shown to influence the association between religion and suicide were not included in our analysis, such as the acceptability of suicide [48]. We also did not examine Chinese values and philosophies such as Confucianism, which has been associated with suicide among young people in rural China [49]. Next, given the larger number of participants who reported not following a religion, the statistical methods employed may suffer from the problem of unequal variances. Many previous studies of suicidality have been conducted in the US and Western European countries, as well as countries with a relatively higher rate of religious affiliation and a dominant religion. Future studies should involve other provinces in China, other age groups, and other relevant subgroups of the population to determine reasons why only Islam appears to be a protective factor, and whether this finding is due to social integration, specific beliefs, religious network, or moral community. Future studies could test our "religious minority hypothesis" in other countries with unique social and political atmospheres, and also to determine whether this pattern is generalizable throughout China. Finally, other aspects of religious affiliation which have been found to be related to suicidality, such as religious importance [50] could also be taken into account in future studies. --- Study implications The association between religion and suicidality is dependent on interactions between the religious denomination, individual factors and the environment in which the individual is practicing the religion. Therefore, we should not generalize past studies which indicated that religion is protective of suicidality across national boundaries, especially for a country such as China with its varied sociodemographic, political and cultural characteristics [51]. That religion may serve as a risk or protective factor in different contexts is important to be noted in health policy-making on suicide prevention, clinical practice, and religious interventions for suicide. This study found that, within the university setting, there are associations between religious affiliation, regional variation, and suicidality. Therefore, religious and regional considerations should be incorporated into prevention and intervention efforts of student mental health care systems. --- All relevant data are within the paper and its Supporting information files. --- Supporting information --- S1 File. --- --- Data curation:

Several past studies indicated that religious beliefs, orientation, and practice are protective of suicide. Findings from recent studies in China suggest that religiosity may contribute to increased suicidality. However, few studies have examined the associations between religious affiliation across different faiths and suicidality in China.The current study examines the association between religious affiliation and suicidality among college students in six provinces in China.We conducted a cross-sectional study involving 11,407 college students from six universities in Ningxia, Shandong, Shanghai, Jilin, Qinghai, and Shaanxi. We collected the data between October 2017 and March 2018 using self-report questionnaires. They included self-report measures of depression, psychache, hopelessness, self-esteem, social support, and life purpose.

Background --- Understanding greenspaces as health promoting community resources Although there is now widespread acceptance from studies of neighbourhood effects that where people live affects their health, the underlying mechanisms are only beginning to be understood [1][2][3][4][5]. One mechanism through which local residential areas affect health and wellbeing is through access to health enhancing greenspace. Epidemiological studies have found that the provision of, and access to, greenspaces is an important determinant of health and health inequalities for both individuals and communities and those with greater access to greenspace report better health [6][7][8][9][10][11]. Mechanisms identified include opportunities to increase cardio-vascular activity, stress reduction and opportunities for interaction for adults and children alike [12][13][14][15]. Access to nature and natural environments can also promote mental health by offering psychological and emotional benefits [16,17]. Evidence that green views from hospital beds can assist recovery further highlights how the benefits of greenspace access go beyond opportunities for physical activity [18]. As a consequence of such findings, lack of access to and/or use of urban greenspace become a public health issue for people living in urban areas. With regard to health inequalities between socio-economic groups, greenspace access has been implicated in social inequalities in obesity and overweight, with parks and other urban greenspaces being viewed as important components of community 'opportunity structures' for health [19,20]. Thus conceived, the equalisation of greenspace quality and access between areas is an important public health action to reduce health inequalities [21,22]. The idea of the 'walkability' of communities has become a focus of research seeking to understand inequalities in access and use of available urban greenspace [23][24][25][26][27]. 'Walkable' neighbourhoods are those urban environments in which people feel comfortable, safe, and predisposed to walk. Those defined as "highly walkable" have been described as being characterised by features such high population density, mixed land use , high connectivity , good pedestrian and cycling facilities and accessibility [28,29]. The inventory of factors shaping walkability has developed to exclude the subjective, less easily captured experiences of urban space. This leaves the individual motivations, values and experiences necessary to ensure greenspaces are visited and re-visited relatively unexplored. Consequently explorations of the relationship between elements of urban infrastructure and health also need to address why people choose, or choose not to use greenspace. While there has been research exploring the connection between physical attributes of local areas and health, most have been conducted using method protocols better placed to capture objective qualities of neighbourhoods such as GIS mapping or surveys. As a result, studies focussing on how places influence health have tended to look at the physical characteristics of neighbourhoods and/or the characteristics of the people who live there [30][31][32]. Less is known about whether the effects of place may affect individuals differently, in a manner that may further entrench inequalities both within and between areas. --- Methods The data for this analysis was collected as part of the Facilitators and Barriers to Greenspace Study conducted by a working group of researchers from the Glasgow Centre for Population Health, the Medical Research Council Social and Public Health Sciences Unit and the local National Health Service board . The study city, Glasgow, is well-resourced in greenspaces but displays significant inequalities in health both within the city and between other areas of the United Kingdom. The study explored the quality and accessibility of greenspaces across two socially contrasting areas of the city to capture subjective understandings of access and quality. The two localities had been the subject of a longitudinal study and the areas were selected from a continuum of eight socio-residential types in the city of Glasgow, the North West locality being towards the 'better' pole and the South West locality towards the 'worse' pole of this continuum, but not at the extremes [33]. The two areas had similar availability of urban greenspace. Indeed the South West area had higher availability . However, when limited to large greenspaces that are managed, the two areas become similar. While there is little change in the North West with the percentage of residents living within 300 metres of managed greenspace greater than 2 hectares decreasing to 25 percent, the shift is more dramatic in the South West, with a drop to 24 percent [34]. --- Qualitative methods For assessing the influence of subjective factors, discussion groups using participatory appraisal techniques and in-depth interviews were utilised. These enabled an indepth exploration of features of decision-making that stemmed from not only living in a particular area but also how the biographical and social context of individuals led to decisions to use, or not use, available greenspace resources. --- Participatory Groups Pilot work with community groups was undertaken to help define the parameters and scope of the data collection in a manner that allowed local people an input. For this we used Participatory Appraisal , a process that allows people to locally determine agendas in consultation. PA is an approach designed to give participants a voice rather than being defined by a rigid set of scientific methods [35]. PA enables people to share their ideas and knowledge about local conditions and allow this expertise to define the nature of local problems. The tools we used were community mapping and H diagrams. Six participatory groups were conducted. Groups were identified and contacted through community hubs. We monitored recruitment to capture a breadth of potential greenspace users, socio-economic statuses, gender and age. The six groups encompassed a pensioners group, a tenants' association and an environmental group , an asylum seeker mothers group, an asylum seeker fathers group and a youth group . The size of groups ranged from 8 to 20. No incentives were offered for participation in the focus groups. --- Community Mapping Participants were provided with A1 sheets of paper and coloured markers and asked to visually map their area marking the location of urban greenspace and other community facilities they used. The subjective nature of the maps offered an important counterpoint to more objective data such as GIS as they introduced perceptual barriers such as presence of intimidating others and individual routine based barriers and facilitators of usage. --- H Diagrams The groups went into more depth through the use of H diagrams that allow people to list both the positive and negative aspects of their communities related to the use of greenspace and community facilities. We asked people to rate their local community greenspace and community leisure resources on a scale of 1 to 10 . This was not intended to be an objective rating but to help focus attention on the issue and to stimulate discussion within the group. After listing the positive and negative features, participants were asked to think about changes that were possible to improve the experience and increase accessibility and usage from their perspectives. --- Individual in-depth interviews and participant photography The primary data were collected through 24 interviews in the two localities . Interviewees were volunteers who had taken part in the previous Health and Wellbeing Survey conducted by the local NHS board. We sampled to achieve an equal balance of gender and socio-economic backgrounds. Prior to the interviews, participants were given disposable cameras and asked to take photographs of their local areas. Photographs provided a participant determined entry point into a discussion about the quality accessibility and walkability of local facilities and experiences of using urban space. Of the 24 interviewees, fifteen returned photographs prior to interviews. Those who had not were asked either about the photographs they had taken but had not yet developed or what they might take a photograph of. Even when photographs taken did not include local parks or greenspaces, the themes stimulated in discussion proved useful in framing discussion of walkability, access and decisions around the use of greenspace. No incentive was provided in recruiting participants for individual interviews. The interview schedule was developed through the themes emergent within the participatory focus groups, covered the following; • Experience of using and accessing local greenspaces. • Availability of areas for walking, playing and generally being active and how they were used. • Changes they would like to see. • How well individuals integrate greenspace use into their daily lives and routines. • How respondents feel living in their area effects their health and wellbeing. The researchers did not collect data on how often the interviewees used greenspace but sought to uncover the reasons why different individuals would use, or choose not to use local greenspace. --- Ethical considerations Participants were recruited from respondents within NHS Glasgow and Clyde's Health and Wellbeing survey who had agreed to be contacted for future studies. As the community sample did not consist of patients, clients or staff of the NHS and involved no invasive procedures, the local NHS Research and Development department waivered the need for ethical approval. Nevertheless, we foregrounded ethical research practice in the design and conduct of the study including informed consent via opt-in , confidentiality of participant data , seeking voices not normally heard and stipulating that photography should not include photographs of people. --- Analysis The visual data were interpreted by the research team and fed into the process of hypothesis formation and the design of interview schedules. In particular, visual data indicated processes and issues over and above those of physical quality and access which presented barriers to greenspace use such as anti-social behaviour, graffiti and conflicts with other greenspace users. The subsequent analysis of interview data was able to explore how individuals experienced and handled such barriers resulting in either the use of non-use of greenspace. Interviews were recorded and either transcribed or had detailed analytical notes taken by one of the researchers . Analytical notes were combined with materials from participatory groups and the interview schedule to develop an initial coding frame within the Nvivo software package [36]. This coding frame was subsequently refined as data was integrated into the data-set. Coding would become hierarchical with time, with variation in a given theme being coded under subheadings of a code. These subheadings could be further divided if required. Analytical codes were checked for salience with the wider research team who had access to transcripts, visual data and had attended participatory groups. We conducted both within-case analysis, exploring each interview as a case study in greenspace usage and access, and cross-case analysis, looking across all 24 cases for both universal themes and issues and also difference . Both analyses were conducted iteratively with each informing the other and coded within the same Nvivo project. --- Results Across all interview data, four key categories emerged in shaping decisions around greenspace usage. These were availability of physical community resources , lifestyle and life-stage factors, individual values and levels of felt integratioIn the analysis presented here we draw attention to the emergence of a particular theme: level of perceived integration as a key issue between cases in shaping greenspace use and access. Although the localities are broadly described as less or more affluent there was socio-economic variation within each area and this diversity is included in our sample. Consequently, a speaker identified as coming from a more affluent area would not necessarily represent 'more affluent' views. Rather than analyse by locality we analysed individual responses to the experience of using and sharing public space. The influence of socioeconomic resources was interpreted as operating at individual level rather than localities. --- Greenspace use, health and wellbeing Beyond the universal recognition from participants that good quality local greenspace promoted exercise and the taking of fresh air, a range of activities relating to broader wellbeing emerged. Differences in how local greenspaces were perceived to promote health and wellbeing reflected the life-course stage and background of users. Consequently, parents of young children sought safe and pleasant spaces to play, those without dependent children prioritised spaces for socialising with others and some prioritised the enjoyment of nature. Young people sought places to 'hang out' without being moved on by the police or other adults. The cited relationships between greenspace and wellbeing reflected the different aspirations, expectations and intentions within greenspace use. Consequently, when it came to improvements people wanted to see, alongside universal claims for high quality greenspaces, the promotion of harmonious greenspace use emerged. Such recommendations could include the installation of CCTV, improved lighting and the return of park wardens or "whistling parkies" as one group referred to them. However, these desires raise a more fundamental question of how community cohesion can be promoted and sustained by public greenspaces in diverse communities were a variety of uses compete in spatially limited spaces. --- Physical availability, quality and access The availability of good quality greenspace was reported as one of a number of facilitators of use. Indeed many users were able to comment on improvement in greenspace availability and quality over the years. However it must be understood as only one of several factors that lead to use; as necessary but not sufficient. Well graffiti, it's not too bad there is evidence of it. Litter is another thing although I've noticed the council making more of an effort perhaps even the local residents, who helped clean up last year. That would be my main issue especially down the river walkways. If you had seen it before the trees grew up there it was just plastic bags all down the river. That's probably been the main thing. I think there is a lack of imagination on the greenspaces, I mean they're small areas around here that tend just to be grassed over and that's it. Rab, more affluent area They've done quite a lot over the last few years to improve that because I guess it had become a bit sort of smelly and horrible so they dredged the pond and built some grass mounds and things in the middle for swans and so it's a bit nicer looking than it used to be. Ailsa, more affluent area --- Individual circumstances and values Alongside quality however, individual life circumstances and associated values needed to configure in such a manner so as to lead to personal preferences and intentions to use greenspace. Quality greenspace would not attract individuals if they had little idea of what to do there. In our data, two value and lifestyle factors dominated the accounts of those who used urban greenspace and these were related to spending time with children and the enjoyment of nature. Well my kids, my kids and that they all go down the park, they like the park. I played down there when I was younger, when I was a kid I played down there all my life and now it's my weans [children] that's going playing football and all that. It's a good bit, a brilliant bit. Derek, more deprived area Not so much now no I don't [use the local park] I probably will because I'm going to have a grandchild soon. Dolan, more affluent area The availability of quality greenspace offers a resource that adults and young people could use, which is reinforced by parenting or grand-parenting values that promote active leisure. We wouldn't let them sit and watch TV, we controlled it a lot, you know. We wouldn't let them have the TV as the focal point all the time you don't want that, you know. A lot of kids, maybe that's all for them nowadays too, maybe they're just couch potatoes, you know. It makes them lazy too, and it's an unhealthy lifestyle. Dolan, more deprived area --- Social cohesion and problems in encountering other greenspace users: self-removal from public space The presence of young people in parks could produce ambivalent feelings from respondents. Many found the presence of unsupervised, older children and adolescents a barrier to greenspace. This finding highlights how community cohesion becomes an important factor in determining greenspace access. The perceptions subgroups have of one another can lead to self-exclusion of some from parks. This self-exclusion becomes an important barrier to greenspace access not captured in understandings of physical quality of greenspace. For Archie accessibility was impeded by the presence of younger people. They could make it a bit more accessible, I don't mean getting there, but I mean it's inhabited by the youngsters now and they're not very friendly youngsters, you know, it can be quite intimidating at times, you know. I think perhaps if they put more effort into maybe policing that park then you'd probably get people having a walk round it. I would rather travel anyway, you know, for a walk I would rather travel somewhere else, you know. Archie, more deprived area The presence of young people could be associated with anti-social behaviour. There were two responses to young people and the issues of graffiti and perceived incivility by adults in the study. These responses appear to have origins in the level of integration and confidence individuals felt in their communities. One response was fear of young people in public space, leading to either a removal of oneself and family from public space or, for those with children, to an increase in the amount of supervision felt necessary. For those who had more resources and choices, exiting public space for private resources was a more easily achieved strategy. The second response was to be stoical about the presence of anti-social behaviour. Stoicism appeared to be grounded in being confident about oneself and having a degree of control. Jack, a fifty-seven year old carer in the North, chose to remove himself from public space on the basis of his experiences with others in his local community. Despite living in the area for thirty years, he felt unable to use the local public greenspaces on account of fears about those he described as "drug users, neds and yobs". When Jack wanted to walk in greenspace, he would take a train to the coast 20 or so miles away. After Jack's home was burgled, he installed closed circuit television cameras reflecting a lack of confidence in his wider community and societal responses to crime. He felt stiffer law and order responses and more police on the beat were required. In terms of local leisure opportunities, Jack chose to join a local private bowling club. While he did not possess a high disposable income, he felt the private club was the only means of securing his safety locally. It's out of control. Law and order has broken down. All they do is put a veneer on it. They use all these initiatives, it's all whitewash, the criminal justice system has broken down ... It's private members' club so you don't get..., it run by ex army and there is a duty officer on and he's responsible for discipline, anybody steps out of line, raising their voice, swearing, anything like that, you're on a charge and they're stricter than the courts. I mean some of them have been sin binned, six months suspension. Jack, more affluent area Jack's choice to use private greenspace facilities reveals that for him, accessibility is not an issue of quality but wider societal issues of cohesion and of shared values. What the private space provides is certainty, viewed as absent in public space, about the values and behaviours with which he will come into contact. --- Social cohesion and problems in encountering other greenspace users: increased supervision of children Naomi dealt with the issue of anti-social behaviour in shared public space differently, choosing to increase the monitoring and supervision she gave to her children to enable them to play outside. Naomi: You're feert to let your kids out on the streets you know the way we used to go out and play, that doesnae happen here. Interviewer: Do you mean because of the traffic or just because of the vandalism or... Naomi: Just because of everything, because of people hanging about and the threat of somebody maybe taking them away or all the fighting and things like that, that go on. Interviewer: It's obviously quite frustrating for you. Naomi: Well, as I say I just take them out myself, if they go out on their bikes we go out with them as well. Naomi, more deprived area Exploration of Naomi's circumstances reveals how she also chose to remove herself and her children from shared public space on account of safety fears. As with Jack, it was not the quality of resources available that prevented her usage, it was the overriding sense that the values and behaviours she found in her community around her were not ones that would ensure safety. Neither was Naomi particularly socio-economically disadvantaged; indeed her access to resources such as a car enabled the removal of herself and children from community resources such as parks, ferrying her children to organised activities such as dancing lessons. The theme of controlling the circumstances, people and values her children came into contact with pervaded. Another individual who selected her public space use with care was Nyela, a female asylum seeker from Somalia, in her twenties with three young children. Nyela differed from Jack and Naomi in a number of ways, not least amongst them that she was socioeconomically more disadvantaged and she described the greenspace she could access as poor quality. The data collected from her came from a discussion group using participatory methods. Nyela and a group of fellow migrant women drew maps that revealed their perceptions of greenspace available to them. Objectively, the area they lived in was well provided for in terms of facilities, a country park was adjacent to the area they lived in. However the greenspace maps drawn by Nyela and her friends depicted only football pitches and low quality green space that flanked the high rises in her neighbourhood. The maps also listed a number of obstacles to greenspace usage such as broken lifts, racist graffiti, gangs of young people "shouting things" and the tendency for flooding after rain . The experience of Nyela and her fellow asylum seekers offers an important counterpoint to the earlier findings about the role of children in promoting greenspace access. Having young children did not always result in use of free amenities such as local parks, as fear of navigating local communities remained a significant barrier. Chosen instead was the local community café, established by a community health project, because it provided feelings of safety and inclusion. --- Stoical responses -strategies to normalise neighbourhood incivilities The second type of response to evidence of anti-social behaviour in public space we coded as stoical responses. These were responses where people recognised the presence of incivilities and anti-social behaviour and noted the deleterious effect it had on the experience of using urban greenspace and public space in general. However, often through attempts to understand the origins of such behaviours, stoics were able to perceive the actions less threateningly. Moira, below, when reporting antisocial behaviour she has suffered attempted to play down its severity . A couple of things, we've had a bit of a spate of vandalism and I know it's fairly low level vandalism it's not as if they are drawing all over our walls or something like that, but there's been some tagging with, I believe that's what they call it, tagging ... So that's a bit disappointing and also about a month ago somebody broke into my dad's car when it was parked outside the house and it happened in the middle of the day. That was disappointing that that happened. It's low level it's not anything, it's not anything that I'm going to get particularly upset about I think it's an annoyance it's not something I get really, really bogged down [with] and, I was very annoyed obviously about my dad's car getting broken into, but in terms of things like the litter and the vandalism I think it's something that happens when you live in a city. Moira, more affluent area Attempts to understand the causes of such incivilities and anti-social behaviour can be interpreted as attempts to maintain a sense of shared values and social cohesion in light of evidence of its possible decline. Such responses are in many ways more hopeful than the previous fearful responses, as the response itself does not further exacerbate the separation of young and old in public space. Yeah, maybe, but I'd like to think it's more that I can understand why these things happen, things like vandalism happens why do we drop litter and hang about streets and stuff like that because they've probably just not got anything else to do and they're bored and fed up and that's just how you find a lot of areas like Glasgow and I think you just accept that that could have been me if maybe I hadn't had the same advantages and I don't like to judge people. Yes I would be annoyed if somebody sprayed painted my windows or something like that, but I'd like to think that once I'd calmed down I could say well there might be a reason why that happened and it's maybe not through fault or it's just a collection of circumstances have led to that and we've all got a part to play really in trying to make sure these things don't happen and people don't really need to do that. Moira, more affluent area A similar logic is in operation in the thinking of Kevin, a middle class parent in the more affluent part of the city. He comments on the presence of young people in public space in more positive terms, even taking account of associated incivilities such as graffiti and behaviour that can often be interpreted as rowdy or potentially threatening. He refers to a local skate park where young people engage in leisure pursuits as offering colour and vibrancy to public space . He finds the growth of corporate monopolies in his community and the homogenisation of his high street to be more anti-social. Difference for Kevin is to be celebrated and encouraged and a benefit of living in a mixed urban community. Kevin is a keen cyclist and therefore a frequent user of public space and perhaps more able to engage with its many aspects. --- Conclusion and Discussion A recent study exploring relationships between environment and obesity in a Canadian city cited a cultural preference for car ownership and use as reducing the potentially beneficial effects of the city's good greenspace quality [37] Such a finding illustrates how elements of local cultures that may promote use of urban greenspace feature combinations of objective and subjective factors. Objectively demonstrable conditions are experienced through subjective and inter-subjective 'rationalities' around the appropriateness of using greenspace as a leisure choice or in daily life. Our analysis adds to this developing understanding by highlighting the role of social cohesion subjectively experienced as how we anticipate and interpret the actions of others in public space. Consequently social cohesion should be understood as an important component of accessibility around urban greenspace. The quality of the greenspace on offer interacts at subjective with the level of social cohesion perceived within a community. Whether the greenspace 'offer' made through infrastructure and provision coincides with individual values and their resulting motivations is an individual level factor that also shaping access.; However, access to personal resources also underpin a sense of social inclusion, when personal resources mitigate the physical evidence of low levels of social cohesion in a community . Where a feeling of social inclusion was absent, the self-removal of individuals from community greenspace resources could be observed. In the cases of those with fewer resources, the removal of an accessible and free at the point of use community resource such as public parks can compound the material disadvantages that underlie population level health inequalities. The findings therefore illustrate the role of social capital, particularly the components of trust, networks of cooperation and strong community identity, in facilitating, access to a health resource and its central role in maintaining wellbeing for all members of the geographical community [38]. The findings indicate support for previous work suggesting aspects of local environments that heighten feelings of insecurity may be mechanisms through which place affects health [39]. One process through which this is played-out for individuals in a manner that impedes access to urban greenspace, is through anxiety about others. Previous research investigating resident's perceptions of walkability in neighbourhoods has found that safety and crime attributes were not as significant as objective, physical attributes in creating a sense of walkability [40]. However, our study, being qualitative, allowed for investigation of how evidence of crime and anti-social behaviour is interpreted by potential greenspace users. This process can be understood as a meeting of a cultural component; the decline in trust and social cohesion between groups and the individual circumstances which shape subjective orientations toward the cultural circumstances at large; feeling confidence that stems from greater social inclusion. Previous research has identified the presence of others as a key facilitator of greenspace use, particular for women however, a decline in trust in communities can make the presence of others a barrier to use and is not always interpreted positively [41]. This local cultural aspect of neighbourhoods or urban areas should be considered alongside quality, availability and connectedness of space and the characteristics of populations. Levels of social cohesion appear a key process variable by which inequalities in access can continue for certain marginalised subgroups once established. In the context of this study, this is experienced as an intergenerational segregation of public space use, between younger and older users. In other contexts the absence of community cohesion may be evident in other ways between different groups, possibly evident through ethnic, gang associated or sectarian division. Segregation in the use of public space highlights one way in which low levels of community bridging social capital mediates individual health inequalities previously identified by researchers such as Cattell and how those with more resources can protect themselves from some of the health consequences stemming from reduced community cohesion [42]. Addressing such an issue currently appears outside the scope of urban planning given that broader societal aspects that underpin feelings of social cohesion are only partly remedied by the provision of community enhancing physical environments. However, given that the inclusion of diverse groups in public spaces can potentially enhance social cohesion, opportunities are currently being missed. As the expertise and resources required to improve the diversity of patronage of our urban greenspaces falls outside the traditional skill sets of urban planners, we suggest the continued and improved involvement of community members and their grassroots organisations, as well as other statutory bodies, in the development of urban greenspace planning and implementation. In some contexts, this may involve conflict-resolution efforts as much as the provision of high quality infrastructure and greenspace. --- Author details 1 Glasgow Centre for Population Health, 94 Elmbank Street, Glasgow, G2 4DL, UK. 2 Medical Research Council Social and Public Health Sciences Unit, 4 Lilybank Gardens, Glasgow, G12 8RZ, UK. Authors' contributions PS designed the qualitative component of the FAB greenspaces study, oversaw and participated in data collection, led on the analysis and interpretation of data and is responsible for the drafting, and argument found within, this manuscript. RJ managed the broader FAB greenspaces study and made contributions to study design, data collection, analysis and drafting of the manuscript. AE was involved in the steering group around the qualitative study, made contributions to analysis and the drafting of the manuscript. All authors read and approved the final manuscript. --- Competing interests Russell Jones is a Board Member of the Glasgow and Clyde Valley Green Network

Background: Greenspace has the potential to be a vital resource for promoting healthy living for people in urban areas, offering both opportunities for physical activity and wellbeing. Much research has explored the objectively measurable factors within areas to the end of explaining the role of greenspace access in continuing health inequalities. This paper explores the subjective reasons why people in urban areas choose to use, or not use, local public greenspace. Methods: In-depth interviews with 24 people living in two areas of Glasgow, United Kingdom were conducted, supplemented with participant photography and participatory methods. Data was thematically categorised to explore subjectively experienced facilitators and barriers to greenspace use in urban areas. Results: From the perspective of current and potential urban greenspace users, access is revealed to be about more than the physical characteristics of neighbourhoods, greenspace resources or objectively measurable features of walkability and connectivity. Subjectively, the idea of walkability includes perceptions of social cohesion at a community level and the level of felt integration and inclusion by individuals in their communities. Individual's feelings of integration and inclusion potentially mitigate the effects of experiential barriers to urban greenspace access, such as evidence of anti-social behaviour. Conclusions: We conclude that improving access to greenspace for all in urban communities will require more than providing high quality resources such as parks, footpaths, activities and lighting. Physical availability interacts with community contexts already established and a holistic understanding of access is required. A key cultural component of areas and neighbourhoods is the level of social cohesion, a factor that has the potential to reinforce existing health inequalities through shaping differentiated greenspace access between subgroups of the local population.

INTRODUCTION The use of social media has dramatically increased in the current era, and researchers have begun to explore the consequences of this phenomenon on the mental health of young individuals . Young people's lives now revolve entirely around social media. Indeed, a recent study revealed that 95% of youngsters utilise social media. Social media can help young people connect with friends, family, and other valuable resources, but it can also harm their mental health. Studies have shown a significant relationship between the use of social media and depressive symptoms among children and adolescents . Concerns about the effects of social media on youth mental health have led to calls for further research in this area. This bibliometric examination explores the interplay among social media, youth, and mental health by scrutinizing the current literature. This analysis emphasizes recognising pivotal research inquiries, patterns, and voids in the existing literature. This research utilised bibliometric analysis through Microsoft Excel 2013 to compute the occurrence and proportion of published materials and generate relevant charts and graphs. Additionally, VOSviewer , a tool for creating citation maps from established databases, was employed, alongside Harzing's Publish or Perish software, to determine citation metrics. In accomplishing this, the analysis is set to enrich comprehension regarding the correlation between the usage of social media platforms and the mental health of the youth demographic. --- LITERATURE REVIEW This section provides a summary of the literature written about the impact of social media on the mental wellness of youth and the role that youth play in the relationship between social media and mental health. A growing amount of evidence connects youth use of social media to mental health issues. For instance, a study produced by Johns Hopkins University Bloomberg School of Public Health indicated that teenagers who used social media for more than three hours per day were likelier to exhibit depressive and anxious symptoms. According to a study by Twenge et al. , young individuals who use social media more frequently self-harm and have suicidal thoughts. Social media can also promote social comparison, which is comparing oneself to others. This can lead to feelings of inadequacy and low self-esteem, especially when young people compare themselves to unrealistic images and standards often portrayed on social media . Youth can be exposed to various harmful content on social media, including cyberbullying, body shaming, and unattainable beauty standards. Depression, low self-esteem, and feelings of inadequacy might result from this. For instance, Janna indicated that 41% of kids felt pressured which seemed inevitable because of social media and 60% of teens had witnessed someone being bullied online. According to Nixon , cyberbullying and harassment can have a serious impact on mental health and happen on social media. Social media use can also disrupt sleep patterns. The blue light emitted from screens can interfere with the production of melatonin. This hormone helps regulate sleep, leading to problems falling asleep and staying asleep, which can contribute to mood disorders . In addition, excessive usage of social media can also foster addictive behaviours because social media can be highly stimulating and rewarding, leading people to use it more and more. This can have a negative impact on mental health, as it can lead to problems such as anxiety, depression, and sleep deprivation . Furthermore, social media reduces face-to-face interaction, which can lead to loneliness and isolation and have a negative impact on mental health . It is crucial to remember that not all young people who use social media experience detrimental effects on their mental health. Personality and coping skills are likely to play a role in the impact of social media on mental health, among other variables. Harmful social media content is more likely to affect some young people than others. Their mentality and ways of dealing are probably to blame for this. For instance, social media content that repeats negative thoughts and feelings may have a more significant detrimental impact on young people who are already dealing with mental health issues . Social media's effects on mental health might also vary depending on how much time is spent on it. Young people who use social media frequently are more likely to encounter unpleasant information and social comparisons. As a result, one may experience despair, low self-esteem, and feelings of inadequacy . The impact on mental health can also vary depending on the social media sites. For instance, social media sites that emphasize comparison, like Instagram, might be more likely to harm mental health than sites that emphasize connection, like Facebook . Another factor to consider is the nature of the interactions on social media. According to Elgar et al. , young people who engage in cyberbullying or who frequently receive critical comments on their social media posts are more likely to suffer from bad mental health effects. It is crucial to remember that not all social media usage is detrimental. In truth, social media can improve the lives of young people when utilized responsibly . For instance, social media can be used to communicate with loved ones, discover new information, and express oneself artistically. Understanding the complexities of this interplay between social media and mental health is essential for developing evidence-based strategies to support the well-being of young individuals in the digital age. Consequently, analysing the existing research landscape is crucial to identifying the key themes, trends, and gaps in this domain. In order to provide a thorough assessment of the state of research in social media, mental health, and youth, this paper presents a bibliometric analysis that methodically analyses an extensive collection of scholarly articles on the topic. This analysis employs rigorous methodologies to investigate publication trends, authorship patterns, citation networks, and theme clusters to identify the main focus areas and contributions from various disciplines. This analysis provides a basis for future research paths, intervention tactics, and policy formation by illuminating the multidisciplinary nature of research and the collaborative networks among researchers. --- METHODS --- Data Source This bibliometric study utilized the scientific database Scopus to analyse publications containing the terms "Generation Z" OR "teenagers" OR "youth" AND "social media" AND "depression" in the title, abstract, or keywords. The study examined all types of papers published in the Scopus database between 2015 and 2022 to provide a comprehensive perspective on the world's research output. Scopus covers publications from diverse geographical locations, offering researchers a worldwide vantage point on advancements in research. This can prove especially advantageous in acquiring a deeper understanding of studies conducted across various regions and cultural contexts. Scopus indexes esteemed and peer-reviewed journals, guaranteeing that the sources researchers come across are of elevated quality and have undergone a specific level of meticulous assessment. The study employed bibliometric analysis, which according to Zupic and Cater , involves a quantitative and statistical evaluation of published studies and is commonly used as a method of conducting a literature review. The present study employed bibliometric analysis using Microsoft Excel 2013 to calculate the frequency and percentage of the published materials and produce the pertinent charts and graphs; VOSviewer , a software that enables the construction of a citation mapping from established databases, and Harzing's Publish and Perish software to calculate the citation metrics. According to van Eck and Waltman , VOSviever software employs two standardized weights, namely the number and total strength of links, to visually represent the nodal network. Additionally, the study utilised Harzing's Publish or Perish as another tool in the analysis. Harzing's Publish or Perish is a software tool that provides a range of bibliometric indicators, including citation counts, h-indices, and publication metrics. The article used this tool to identify the most influential authors and publications in social media, mental health, and youth. Researchers used a WordArt tool to visualize the author's keywords, which generates a graphic representation of the most frequently occurring words in a text. The researchers input the author keywords from each publication into the WordArt tool and used the resulting visualisations to better understand the key themes and topics in the literature. --- Defining keywords This research was performed on June 26, 2023, using keywords in search strings relevant to social media, mental health, and youth, where keywords are searched based on the title, keywords, and abstract of the article as follows: TITLE-ABS-KEY AND PUBYEAR > 2010 AND PUBYEAR < 2023 AND OR LIMIT-TO ) AND OR LIMIT-TO ) AND ) --- Search strategy This study gathers materials published on social media, mental health, and youth interconnection using the online Scopus database. Due to its reputation as the largest citation and abstract database in technology, social science, business, and management, the Scopus online database was chosen for this study. --- Refinement of Search Result After obtaining the initial results, the researchers screened all articles based on the exclusion criteria determined in this research. There are two exclusion criteria used to filter the search results: sexual harassment artificial intelligence social anxiety transgender adolescents. Table 1 summarises the total number of articles obtained after the refinement process. --- Table 1. Refinement of search result --- Search Keyword Number of Scopus documents TITLE-ABS-KEY AND PUBYEAR > 2010 AND PUBYEAR < 2023 AND OR LIMIT-TO ) AND OR LIMIT-TO ) AND ) --- RESULTS In analysing the academic works extracted during the search process, the following attributes were considered: document and source types, the language of documents, subject area, year of publication, the top 20 countries that contributed to the publication, the most active source titles, citation metrics, the top 20 highly cited articles, and keyword analysis. These attributes were utilised to understand the trends and patterns in the literature on the interconnection of social media, mental health, and youth. --- Document and Source Types Table 1 presents an overview of the distribution of publications according to their document types. The table provides information on the total number of publications, categorised as "Article" and "Conference Paper," along with their corresponding figures and percentages. Out of the 58 publications analysed, the majority, accounting for 84.48% , were classified as articles. On the other hand, conference papers constituted a smaller portion, representing 15.52% of the total. These findings shed light on the relative prevalence of different document types within the analysed dataset, suggesting a higher frequency of articles than conference papers. --- Year of Publications/Evolution of Published Studies Table 3 presents an in-depth analysis of the publication years within the dataset, providing valuable insights into the temporal distribution of the publications. The table includes information on the total number of publications for each year and their corresponding percentages and cumulative percentages. The most recent year in the dataset is 2022, accounting for the highest number of publications at 39.66% . This suggests a significant concentration of research activity in the most recent year, reflecting the timeliness and currency of the dataset. The preceding years also demonstrate notable contributions, with 2019 comprising 8.62% and 2020 accounting for 24.14% . These findings indicate consistent research output in the years immediately prior to the dataset's timeline, suggesting ongoing scholarly engagement and productivity. Additional years, such as 2018, 2016, and 2015, represent a smaller fraction of the dataset. These years contributed 1.72% each, indicating a relatively limited presence within the dataset. However, their inclusion provides a historical perspective and highlights the incorporation of earlier research contributions. The cumulative percentages help contextualize the distribution of publications over time. It can be observed that the cumulative percentage increases gradually, reflecting a cumulative accumulation of publications across the years analysed. By considering the cumulative percentage, it is evident that a significant proportion of the publications were published within the four most recent years . Overall, this table provides a comprehensive overview of the publication years within the dataset, offering insights into the temporal trends and concentration of research output. The concentration of publications in recent years suggests an emphasis on contemporary research, while the inclusion of earlier years adds historical context to the dataset. --- Languages of Documents Table 4 presents a concise summary of the languages utilised for publications within the analysed dataset. The table provides information on the total number of publications and their respective percentages, focusing specifically on the language used. The analysis of 58 publications reveals that English was the exclusive language employed in all publications, constituting 100.00% of the total. One document within the dataset was prepared in dual languages, implying that it contained content in both English and another language. However, most publications were conducted solely in English. These findings underscore the dominant role of the English language as the primary medium for scholarly communication within the analysed dataset. English's global prevalence as the language of academia facilitates the dissemination and accessibility of research findings across international boundaries, promoting broader knowledge exchange and collaboration. publications) of the total. This suggests a significant emphasis on medical research within the analysed publications. Psychology is also a notable subject area, accounting for 24.14% . This highlights the significance of psychological studies within the dataset. Other subject areas that contribute to the overall publication landscape include Computer Science , Engineering , Social Sciences , Decision Sciences , and Arts and Humanities . Additional subject areas, such as Business, Management and Accounting, Environmental Science, Mathematics, Neuroscience, Pharmacology, Toxicology and Pharmaceutics, and Nursing, each account for a smaller proportion, with one or two publications in each respective area. These findings provide valuable insights into the subject areas covered by the analysed publications, illustrating a diverse range of research domains. The predominance of Medicine and Psychology publications suggests the significance of these fields within the dataset. At the same time, other subject areas demonstrate a multidisciplinary approach and the inclusion of various academic perspectives. --- Most Active Source Titles Table 6 analyses the top 20 most active source titles regarding the number of publications they contributed to the dataset. The table provides information on the total number of publications associated with each source title and their respective percentages. Among the top 20 most active source titles, the International Journal of Environmental Research and Public Health emerges as the leading source, with 6.90% of the total. This suggests a significant focus on environmental research within the dataset, with this journal serving as a prominent outlet for related studies. Several other source titles exhibit a notable presence, albeit with smaller contributions. These include the Journal of Adolescence and Adolescent Health, each accounting for 3.45% of the total. The Pediatric Annals, Acta Psychiatrica Scandinavica, Acta Psychologica, and Addictive Behaviors Reports are also represented, contributing 1.72% to the overall dataset. The remaining source titles in the top 20 encompass diverse fields such as psychiatry, psychology, computational sciences, education, and youth services. While each source title contributes only one publication, their inclusion in the list signifies their relevance within the scholarly discourse and their publication output within the dataset. Overall, this table sheds light on the most active source titles, providing insights into the diverse range of journals, conferences, and publications contributing to the analysed dataset's research landscape. It underscores the prominence of particular sources in specific fields while reflecting the multidisciplinary nature of the scholarly community's output. presents a comprehensive analysis of the top 20 keywords found in the publications within the dataset. The table provides information on the total number of publications associated with each keyword and their respective percentages. --- Keywords Analysis The most frequently occurring keyword is "Social Media," appearing in 72.41% of the total. This indicates a substantial focus on the influence of social media platforms within the dataset, underscoring their significance in contemporary research. Other prominent keywords include "Human" , "Depression" , "Adolescent" , and "Female" . These keywords reflect the key themes and topics explored within the dataset, highlighting the attention given to mental health, specifically in relation to adolescent populations. Additional keywords such as "Article," "Humans," and "Mental Health" appear frequently, each appearing in 39.66% of the dataset. These keywords denote general descriptors and areas of focus within the analysed publications. Furthermore, keywords such as "Male," "Anxiety," "Psychology," "Adult," and "Child" are also represented, demonstrating a diverse range of topics and populations examined within the dataset. Several keywords relate to specific research methodologies or study designs, including "Crosssectional Study," "Controlled Study," and "Major Clinical Study." These keywords indicate the prevalence of these research approaches within the analysed publications. The presence of keywords such as "COVID-19," "Cyberbullying," and "Social Networking " suggests a focus on contemporary issues and their impact on mental health and social behaviour. Overall, this table provides valuable insights into the prominent keywords within the dataset, shedding light on the central themes, populations of interest, and research methodologies employed. The identified keywords showcase the multidimensional nature of the research and highlight the key areas of focus within the analysed publications. --- Geographical Distribution of Publications -Most Influential Countries Table 8 analyses the top 20 countries that have contributed significantly to the publications in the dataset. The table presents information on the total number of publications associated with each country and their respective percentages. The United States emerges as the most prolific contributor, with 46.55% of the total. This indicates a substantial research output from the United States within the analysed dataset, highlighting its prominent role in the scholarly discourse. India is the second most active country, accounting for 15.52% . Australia and the United Kingdom share the third position, contributing 6.90% . These findings demonstrate a significant research presence in these countries, emphasizing their contributions to the dataset. China, Canada, Hong Kong, Italy, Japan, South Africa, and South Korea are each represented by two publications, amounting to 3.45% each. These countries showcase their active engagement in the research domain and noteworthy contributions to the dataset. Furthermore, several countries, including Bangladesh, Brazil, Kyrgyzstan, Malaysia, Mexico, Nepal, Nigeria, the Philippines, and Poland, are each associated with one publication, contributing 1.72% to the overall dataset. Overall, this table provides insights into the geographic distribution of research contributions within the analysed dataset. The dominance of the United States in terms of the number of publications underscores its influential role in the scholarly landscape. Additionally, the inclusion of various other countries signifies a diverse range of global research perspectives and highlights their contributions to the dataset. --- Unit of analysis = Countries Counting method: Fractional counting Minimum number of documents of a country = 1 Minimum number of citations of a country = 0 --- Text Analysis Figure 5 presents a VOS viewer network visualization map of the author's keywords using binary counting. The map identifies two clusters based on the keywords and assigns them colours for clarity. Cluster 1, depicted in red, consists of eight items: covid, depression, internet, life, pandemic, person, young person, and youth. These keywords likely represent a group of research themes or topics related to the interconnection between social media, mental health, and youth. The cluster suggests that there is a significant focus on understanding the impact of the COVID-19 pandemic, internet use, and depression on the mental well-being of young individuals. Cluster 2, shown in green, comprises six items: association, data, depressive symptoms, relationship, suicide, and teenage. These keywords indicate another set of research themes or topics that likely explore associations between variables such as depressive symptoms, suicide, relationships, and data related to social media, mental health, and youth. The cluster may represent studies investigating the relationships and factors associated with mental health outcomes in relation to social media use among teenagers. Overall, the visualization map of the author keywords in Figure 5 provides an overview of the main thematic clusters within the literature, highlighting key topics and associations in the research on the interconnection of social media, mental health, and youth. --- Most Influential Institutions Table 10 lists the top 20 most influential institutions based on their contributions to the publications within the dataset. The table includes information on the total number of publications associated with each institution and their respective percentages. Several institutions emerge as highly influential within the dataset, each contributing two publications, accounting for 3.45% of the total. Table 10 provides insights into the influential institutions associated with the publications in the dataset. The presence of renowned institutions, such as Harvard Medical School and Georgetown University, underscores their significant contributions and expertise in the field. Moreover, the inclusion of diverse institutions from different regions and sectors demonstrates the global and interdisciplinary nature of the scholarly discourse within the analysed field. --- Citation Analysis Table 11 provides an overview of the citation metrics for the publications within the dataset. The table includes information on publication years, citation years, the total number of papers, the total number of citations, and various derived metrics. The publication years span from 2015 to 2022, indicating the temporal scope of the dataset. On the other hand, the citation years cover a period of eight years, from 2015 to 2023, highlighting the timeframe during which citations have been accumulated. A total of 58 papers are included in the dataset, which has collectively received 1331 citations. This suggests a significant level of scholarly engagement and recognition within the field. The citations per year metric provides an average of 166.38 citations received per year across the eightyear citation period. This metric offers insights into the annual impact and visibility of the publications within the dataset. The citations per paper metric indicate an average of 22.95 citations received per paper, showcasing the level of scholarly attention and impact each paper has garnered. The citations per author metric reveal that, on average, each author associated with the publications has received 304.2 citations. This metric reflects the individual research impact of the authors within the dataset. The papers per author metric indicate an average of 3.83 papers authored by each author, highlighting their level of research productivity and contribution to the dataset. The h-index, a widely used metric in citation analysis, is 11 in this case, suggesting that 11 papers within the dataset have received at least 11 citations each. The g-index, another citation-based metric, is 36, indicating that the top 36 papers in terms of citation count cumulatively account for a substantial portion of the total citations received within the dataset. Overall, Table 11 provides comprehensive citation metrics that offer insights into the impact, productivity, and visibility of the publications within the analysed dataset. These metrics serve as valuable indicators of scholarly influence and contribute to the assessment and evaluation of research contributions within the field. --- DISCUSSION The interconnection of social media, mental health, and youth is a complex and evolving topic that has gained significant attention in recent years. By examining an extensive collection of scholarly articles, we have identified key trends, influential authors and institutions, and thematic clusters within the literature on social media, mental health, and youth, identifying important publications, authors, institutions, and countries contributing to this field. The results indicate that the number of publications on this topic has been increasing, with the highest number recorded in 2022. The United States was found to be the country with the highest number of publications, followed by India, Australia, and the United Kingdom. The geographic distribution of research contributions emphasizes the influence of the United States and the diverse global perspectives represented in the dataset. The study also identified Moreno, M.A., Nicholas, J., Twenge, J.M., and Vishwakarma, D.K. as the most productive authors. E. Bailey, A. Boland, I. Bell, J. Nicholas, L.L. Sala and J. Robinson's article is the most highly cited article in this field. These findings provide valuable insights for researchers and practitioners on this field's most influential authors and publications. The study's findings also revealed the most influential institutions in this field, including California State University, Fullerton, the University of Pittsburgh School of Medicine, and Florida State University. These institutions' research outputs highlight their contribution to this field and can guide future research collaborations and partnerships. One theoretical framework that can be applied to the findings is the Social Cognitive Theory proposed by Bandura . According to SCT, cognitive processes, observational learning, and selfefficacy beliefs influence individuals' behaviours. In the context of social media and mental health, SCT can help explain how exposure to certain content on social media platforms can shape young individuals' beliefs, attitudes, and behaviours related to mental health. Future research can explore the role of SCT in understanding the mechanisms through which social media use affects mental health outcomes among youth. Another theoretical framework that can be relevant is the Transactional Model of Stress and Coping by Lazarus and Folkman . This model emphasizes the dynamic interaction between individuals and their environment in stress appraisal and coping. In the context of social media and mental health, this framework can shed light on how social media use can serve as both a stressor and a coping mechanism for young individuals. Future research can investigate the specific stressors and coping strategies related to social media use and their impact on mental health outcomes. From a practical standpoint, the findings of this analysis have important implications for various stakeholders, including parents, educators, mental health professionals, and policymakers. Identifying key themes, such as the impact of the COVID-19 pandemic, internet use, and depression on youth mental health, highlights the urgent need for targeted interventions and support systems. For example, educational programs can be developed to promote digital literacy and responsible social media use among young individuals. Mental health professionals can integrate social media platforms into their interventions and provide evidence-based guidance on navigating the online environment. Policymakers can use these findings to inform the development of regulations and guidelines to protect the mental well-being of youth in the digital age . In conclusion, this bibliometric analysis contributes to a more comprehensive understanding of the interconnection between social media, mental health, and youth by drawing connections to relevant theoretical frameworks and practical implications. The application of theoretical frameworks, such as Social Cognitive Theory and the Transactional Model of Stress and Coping, can provide insights into the underlying mechanisms. It is important to note that research in this field is ongoing, and findings may vary across studies. While there is literature on this subject, the paper identifies the shortcomings of earlier research, including the absence of thorough bibliometric analysis and the exclusion of several pertinent themes and populations. The impact of social media on mental health is influenced by various factors, including individual characteristics, patterns of use, and the specific platforms involved. While social media platforms offer numerous benefits and opportunities for communication, information sharing, and community building, they can also impact young people's mental health and well-being in various ways. literacy initiatives, online mental health interventions, and tactics to encourage young people's resilience and positive online involvement. Due to the study's bibliometric methodology's concentration on numerical data-such as publication numbers and citation counts-rather than qualitative insights that may have provided a more profound understanding, the study has limitations. There is a danger that publication bias will influence the findings because the study only considers papers from the Scopus database and overlooks potentially relevant research from other sources and databases. The scope of the study may have been constrained by the criteria used to omit significant studies during the refinement phase inadvertently. The study may have a linguistic bias and exclude important opinions published in other languages because it only looked at Englishlanguage articles. The study's results might also not accurately reflect the rapidly evolving digital landscape and fresh social media trends because they are based on previously published data. The results of this study can be extended and improved by future research on the relationship between social media, youth, and mental health by pursuing different lines of investigation. Longitudinal studies are essential to understand the long-term effects of social media use on young people's mental health and to track causal relationships and underlying mechanisms across time. Additionally, research into the various functions of particular social media platforms and their characteristics in affecting young people's mental health outcomes is crucial because each platform's special characteristics may have a different effect, guiding the development of customised interventions and safe usage recommendations. Future research must focus on the potential positive effects of social media on youth mental health, uncovering how it can catalyse mental health awareness, support networks, and positive social ties, whereas existing literature frequently emphasises negative repercussions. In addition, it is crucial to recognise the complex interactions between social media, mental health, and young people within the context of intersectionality, which includes factors like gender, race, ethnicity, socioeconomic class, and sexual orientation. This investigation can shed light on disparities and inequities, guide intervention measures, and promote equitable health. Finally, there is a critical need for research assessing the effectiveness of interventions and strategies intended to support juvenile mental health while minimising the negative effects of social media use. In order to do this, it is necessary to evaluate the impact of programs that promote digital literacy, online resources for mental health, and laws limiting young people's access to social media. In conclusion, this study contributes to the body of knowledge on the interconnection of social media, mental health, and youth that can grow and contribute to evidence-based practices, policies, and interventions that promote the well-being of young individuals in the digital era. As the digital age continues to shape the lives of youth, understanding the implications of their digital interactions on mental health remains pivotal. Social media, mental health, and youth interconnections bring together researchers from diverse disciplines, such as psychology, sociology, communication, and public health. This collaboration fosters the exchange of ideas, methodologies, and perspectives, leading to a more comprehensive and holistic understanding of the topic. --- Among the top productive authors are Moreno, M.A., Nicholas, J., Twenge, J.M., and Vishwakarma, D.K., each with two documents, accounting for 3.45% of the total publications individually. Other authors listed in the table have contributed one document each, representing a range of 1.72% of the total publications. These authors have made noteworthy contributions to the research literature in the field, and their work has influenced the overall knowledge and understanding of the topic. Their diverse perspectives and expertise have enriched the body of knowledge in the area of study. --- CONCLUSION The interconnection between social media, mental health, and youth is a topic that has garnered significant research interest. Numerous studies have explored social media's impact on young individuals' mental health. Findings suggest that excessive social media use can be associated with negative mental health outcomes such as depression, anxiety, loneliness, and decreased self-esteem. The significance of this study lies in its contribution to understanding the interconnection between social media, mental health, and youth. Through a bibliometric analysis of many academic articles, this study sheds light on the evolution of research trends and patterns related to social media, mental health, and youth. It identifies the countries of authors that contribute the most to the publication of social media, mental health, and youth research, as well as the most frequently cited studies and the most influential authors and research groups in the field. A bibliometric analysis of this topic reveals an increasing number of publications, with the United States being the leading contributor, followed by India, Australia, and the United Kingdom. Prominent authors and institutions were identified, highlighting their contributions to the field. While social media platforms offer benefits for communication and information sharing, their impact on youth mental health is influenced by individual characteristics and platform usage. It is crucial to continue exploring this topic to better understand the interplay and promote the well-being of young people in the digital age. Additionally, this study has theoretical implications for the academic community by giving a thorough summary of the most recent studies on the relationship between social media, mental health, and youth. This study recommends the use of theoretical frameworks since they can reveal the underlying mechanisms, including Social Cognitive Theory and the Transactional Model of Stress and Coping. The academic community can concentrate on creating and assessing interventions that seek to lessen the adverse impacts of social media on juvenile mental health by building on study findings. This involves creating digital --- CONFLICT OF INTEREST STATEMENT The authors declare no competing interests. --- AUTHORS' CONTRIBUTIONS All authors contributed to the conception and design of the study. Nurliyana Abas and Hanani Hussin conducted the bibliometric analysis, while Norafiza Mohd Hardi and Norhafiza Hashim analyzed the survey data. Nurliyana Abas and Hanani Hussin. drafted the manuscript, and all authors contributed to the critical revision of the manuscript. All authors approved the final version of the manuscript for submission. All authors agree to be accountable for all aspects of the work and ensure that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

This study explores social media, mental health, and youth interconnection and proposes potential future research directions. Utilising bibliometric analysis, we examined a selected set of 58 papers from the Scopus database, focusing on the study conducted between 2015 and 2022 that explored the interconnection of social media, mental health, and youth. We gained insights into the most significant contributions in this domain by assessing citations, publication locations, relevance within the research network, and influential articles and authors. Additionally, we conducted a thorough analysis of topics, identified barriers to expansion discussed in the literature, and recommended potential avenues for further investigation. The data was processed using the Publish or Perish software, while the researchers used a VOS viewer for data visualisation. Statistical analysis was performed using Microsoft Excel. The study presents a comprehensive bibliometric analysis, including trends in publication growth, research output, and citation analysis. Our search yielded 58 documents, with an increasing trend observed in studies on social media, mental health, and youth. English dominated most research papers, primarily published in journals and conference proceedings. The writers Moreno, M.A., Nicholas, J., Twenge, J.M., and Vishwakarma, D.K. are recognized as the most productive authors. The United States has emerged as the leading nation in publishing output. The survey lists the most significant academic centres, such as Florida State University, California State University, Fullerton, and the University of Pittsburgh School of Medicine. Two significant thematic clusters are revealed by keyword analysis: one focusing on the effects of the COVID-19 pandemic, internet use, and depression on young people's mental health, and the other investigating the relationships between elements like depressive symptoms, suicide, relationships, and social media use. The study suggests that theoretical frameworks like Social Cognitive Theory (SCT) and the Transactional Model of Stress and Coping can aid in understanding the mechanisms through which social media impacts Keywords: social media depression mental health youth adolescent transactional model of stress and coping

The aim of this study was to understand how key influencers uphold and transmit information and norms about FP, and explore who women consult as they make FP decisions and why they consult these key influencers. --- Introduction In 2014, 61.8% of women living in urban areas in Kenya were using modern family planning methods [1]. This average hides differences in FP access for women living in informal settlements who are disadvantaged in both the availability and quality of FP methods, resulting in lower uptake of FP [2][3][4] and a higher unmet contraceptive rate than other urban areas [3]. Women's uptake of FP methods is shaped by global and national level investments in women's health, access to health services, knowledge and awareness about FP, and gendered power dynamics within household and communities which shape decision-making freedoms [5][6][7]. A growing number of studies show how social norms-the unwritten rules of common and appropriate actions-within women's social networks affect women's decision to use FP methods and the uptake of FP [8][9][10]. Women do not make FP decisions in isolation, but rather rely on their social networks to verify and gather information on the benefits, side effects, timing, and cost of FP [11]. A study among Kenyan women showed that young women, in particular, value other people's experiences and advice about FP more than information from health providers when making decisions about FP [12,13]. Studies in Tanzania [14], South Africa [15] and Angola [16] have also found that social networks strongly influence young women's decision to use FP. Social norms, and the fear of negative social sanctions, related to the use of FP could deter young women from seeking information or accessing FP [17,18]. In addition to social norms, Barker and colleagues link gender norms-social norms that specifically apply to people of a given gender-as among the most important factors that continue to influence FP uptake [19,20]. Gender norms affecting young women's use of FP, especially among unmarried young women, include the belief that using FP will be associated with infidelity or prostitution [9,21] and that women are expected to marry early and have children soon after [22]. Social and gender norms theory draws attention to the importance of 'key influencers' who shape and reinforce social norms over time [23][24][25][26][27]. Prior studies show that 'key influencers' on young women's FP decisions, often focusing on family members, partners and friends as key influencers [28,29]. These key influencers often play different roles in promoting-or stigmatising-the use of FP. Studies show that while parents have been apprehensive about a young woman's use of FP [30], young women identified their mothers as important and trusted figures to discuss FP choices [28]. Partners are seen as key decision makers in young women's FP use as they are involved in discussions around desired family size [29,31,32]. Young women have also identified healthcare workers as key influencers in their FP decision making since they are trusted to provide accurate information [33]. However since healthcare workers are required to access FP methods, it has also been shown that healthcare workers may restrict method use based on a woman's marital status, age or parity [34,35]. Taken together, the evidence suggests that young women access FP information from multiple members of their social circles, despite cultural and normative barriers associated with FP [9,10,36]. This paper will explore who the key influencers of FP are within peri-urban Nairobi, with an emphasis on other key actors in social networks than parents and partners, and fills a gap in the literature about how young women navigate their normative context to acquire FP information from various members of their social networks. In this paper, we draw on qualitative interviews with women and key influencers to examine how partners, parents, aunts, and friends uphold and transmit social normative information about FP, and the implications of these key actors on women's decision making around FP use. We explore who women consult as they make decisions related to their FP use, why they consulted these key influencers, and how women navigate stigma, support and advice from key influencers, and the varying influence of different individuals within women's social networks. --- Methods --- Participants and study sites Phone interviews were conducted with 40 participants across 7 wards in Nairobi in November 2020, during the COVID-19 pandemic. Peri-urban wards were purposively selected based on whether they had health centers and FP services operational at the time of data collection. These wards are part of urban informal settlements in Nairobi with a lack of durable housing, limited access to adequate water, sanitation, refuse collection, and health services. Participants were 16 women between 18 and 25 years of age, 10 partners and 14 key influencers . Women were randomly sampled from a panel of participants which the Busara Center for Behavioural Economics had recruited between 2014 and 2020. The panel included 66,407 respondents living within Nairobi, 33,829 of which were women. Due to safety considerations for phone-based data collection, women had to have their own smartphone to participate in the study. The women interviewed were 20-25 years old and most had some secondary education or higher. Nine women reported being unemployed, two were employed, one was a student, three worked casual jobs and one was a homemaker. More than half of the women interviewed were using contraception. In the interviews, women first described who they went to for advice on FP. Partners and key influencers were purposively sampled from the panel of participants with similar sociodemographic characteristics to the persons that women described in their interviews. These participants did not reside in the same households and were not from women's own social networks due to safety and privacy considerations, particularly during COVID-19. Partners were between 23 and 32 years old , most of whom were employed and had secondary or university education . Key influencers were aged 23-52 years , most of whom were partnered , had 3-4 children and were employed . More information about participant sociodemographic characteristics are available in Additional file 1. --- Study design Qualitative interviews were part of the formative phase of a larger study, which aimed to examine how an online digital media intervention influences social norms around FP use among young women, and served to inform and contextualise the content of that intervention. The study was a collaboration between researchers from institutions in the Global North and South , who were involved in each stage of the study. We worked together to co-design the study and collaborate on data collection and analysis. We reflected on our positionality, contributions and limitations throughout the study and discussed how our preconceptions and assumptions could shape the study design, analysis and interpretation. To mitigate the bias associated with our positionalities and assumptions, all members of the research team participated in coding, analysis and writing. The semi-structured interview instrument was designed to explore social norms and sanctions of accessing and using FP, sources for information and decision making on FP, women's social media use and the effects of COVID-19. To understand young women's experiences accessing information or FP methods, respondents were asked to reflect on their own experiences and/ or the experiences of other women through the use of a vignette of a 23-year-old young woman named Wanjiku who lives in the same neighborhood as participants with her parents and siblings and is considering using modern FP methods including condoms , pill, patch, ring, diaphragm, injection, IUD, implant and sterilization. Participants were asked: Who are the top two people Wanjiku would consult when deciding about FP that would influence her decision? Why would she reach out to this person? What might this person have said about FP to Wanjiku? How might the conversation with this person change what Wanjiku's will do about FP? More information about the vignette is available in Additional file 2. Accordingly, some answers from participants were from their own perspective and from other women generally or the character of the vignette specifically . The respondents' perspectives on who women trust for advice on FP are captured in the findings below. --- Data collection Data were collected by a team of four trained researchers from Busara who had prior experience conducting qualitative interviews in English and Swahili. Prior to data collection, all researchers participated in a three day training covering topics on social norms, good data collection and management practice, the study's design and the interview guide. The qualitative instrument was piloted internally, with study staff and the data collectors, and then piloted with 10 participants. The instrument was revised after each pilot. Data collection was phone-based and took place in November 2020 during the COVID-19 pandemic. Researchers contacted participants who met the inclusion criteria via phone to assess eligibility, explain the study design and schedule a phone interview time. Information about the study was also sent via What-sApp. Consent was audio recorded, which was iteratively checked-in throughout interviews through: the means of a safe word for participants to use should the conversation no longer be private, check-ins about privacy and comfort, and the use of a vignette to discuss sensitive subjects. Interviews were conducted in either English or Swahili, depending on the participant's preference. Participants were sent phone credit and a list of local resources and health facilities to access more information on FP and access support for gender-based violence, which were open during the COVID-19 pandemic. The research team conducted daily debriefs during data collection to discuss emerging themes and to check-in about the safety and comfort of participants during interviews. After data collection, the Busara research manager checked whether consent was sought and reviewed audio recordings. A Busara researcher who had not conducted the interviews translated and transcribed the interviews. The quality of transcription was checked in a random selection of transcripts, which were compared to audio recordings by a study manager who did not conduct or transcribe interviews. --- Data analysis We conducted a thematic analysis. We developed an initial codebook based on our research questions. To revise the codebook, all authors discussed codes and themes. Following standard procedures in thematic analysis, we first coded the transcript by both using the codes in the codebook, remaining open to emerging new codes. New codes were discussed by all coders as they emerged and were integrated in the codebook. As we coded, we specifically paid attention to potential deviances from what most participants said, mindful of the importance of analysing the data both with and against the grain [37]. As we continued this first step of the analysis, we reached a point of saturation, when the raw data did not seem to yield any codes. Then we gathered similar codes in larger themes. For the current paper, we focused on themes that described who women would consult as they make decisions related to their FP use and how and why they consulted these key influencers. --- Ethical approval Permission to conduct this study was obtained from Strathmore University, Nairobi and the London School of Hygiene and Tropical Medicine . Participants provided verbal consent prior to interviews and identifying information was removed from transcripts prior to analysis. --- Results Participants identified five groups of people who influenced their decision making about FP: Parents, aunts, partners, friends and healthcare workers. While most women, partners and their key influencers said that parents were important to consult on matters related to FP, nearly every woman said that mothers were more supportive than fathers. Specifically, mothers could understand the social risks of using FP and could advise their daughters on how to do so in discreet ways. Besides mothers, aunts were seen as approachable sources of information on available FP methods including the benefits and drawbacks of using them. Participants saw women's partners as key decision makers and friends as important sources of emotional support. Lastly, women and their key influencers trusted healthcare workers to be impartial, confidential, and knowledgeable sources of information and advice on which FP methods to use. In passing, two women identified other trusted community members, including religious leaders and a mother's older friend, as sources of FP information. We discuss the role of each of these key influencers in shaping how women engage with FP information, services, and methods. --- Parents Women largely preferred mothers to fathers when they needed to talk about FP. In explaining their choice, most women echoed one participant who said: "A mother wants what's best for her [daughter]" . Partners and KIs agreed, suggesting mothers have personal experiences to advise their daughters: "They can relate with each other-there are those daughters who are free with their mothers and can share anything with them" . This emotional closeness was evident when some women described that mother's advice-giving centered around experiences of having "suffered" from financial or health consequences of having many children or having children early. One woman said that a mother would tell her daughter to learn from her experience and use FP because "the mum has gone through a tough life, bearing a lot of children because she never wanted to use family planning" . Several women described that "suffering" would motivate mothers to recommend FP so their daughter could avoid the constraints associated with childbearing: "The mum will advise her to use family planning not to end up like her" . Other women noted that if a mother is not aware that she had "suffered" in the past, then she will not recommend FP as she would not understand the value of FP: "It will depend on the background of Wanjiku's mother. If Despite relatively high trust in their mothers, several women expressed reservations about fully confiding in their mothers. One woman, in response to the vignette where a daughter considers speaking with her mother on FP, said"I don't know if she trusts the mom. I won't say she trusts the mom yet but she just wants to make her aware of it [her family planning use]" . One reason for hesitating to share openly about FP use was the worry about tarnishing the family's or their own reputation. A few women acknowledged that their actions of accessing or using FP could still confer shame to their families: "Her parents will take her to be immoral" . Mothers, likewise, were susceptible to community judgment in relation to an unplanned pregnancy in addition to FP: "Her mother can notice she has a boyfriend and she can advise her to use a condom with him and not bring shame to her" . A few women added that being seen purchasing FP could also be shameful and anticipated a mother would advise being more secretive, "[The mother] will be like, did you have to go there [to the chemist] while everyone is seeing you? You are embarrassing me" . Women recognized that mother's reputations were closely tied to their own reputations, however, this was sometimes in tension with wanting a better life for their daughters: "Her mom will see that instead of Wanjiku bringing her a grandchild in the house, it is better she protects herself [by using FP]" . Women weighed prescribed norms of chastity before marriage, the fear of disappointing their families by using FP to prevent shame or pregnancy alongside the risk of 'suffering' associated with early pregnancy. While participants overwhelmingly referring to mothers as the key parent women would speak to, almost none of them held fathers in the same regard. Only one participant said fathers would be supportive of their daughters discussing or using FP: "Because they [fathers] can't let their child down with bad advice" . Participants said women wouldn't talk to their fathers primarily for two reasons: They wouldn't know how to start a conversation on such a sensitive topic with them, and they would be scared of their fathers' reaction. While mothers were considered a "fellow woman" , a daughter "will not even have an idea how to start such a conversation with the father" . Most participants said women would be ashamed to talk about FP with their fathers: "It [talking about FP use] is shameful, sharing that with the father" . Not only were participants ashamed to talk to their fathers about their reproductive health, but a few also mentioned fearing fathers' possible reactions. One woman, for instance, said, "her father might be interested in knowing where Wanjiku learnt about family planning and even become a nuisance to Wanjiku's mother" . Partners and KIs said that fathers would react negatively to learning about a daughter using FP, as that would imply she was having premarital or early sexual intercourse, "especially when they realize their children have started involving in many things [sexual activities]" . In some circumstances the anticipated reaction from fathers could be more severe than in others. A couple participants noted that a father's anger about their daughter's FP use could sometimes escalate to violence: "[The father] can beat her up" . Partners also suggested that there was potential violence if a father finds out about his daughter accessing or using FP: "Because if I were the Dad and she happens to come for such advice [about FP], I would beat her up. There are issues that are supposed to be shared with the mum and not the dad" . A few participants described a risk to women who live with their parents being forced to leave the home due to parents learning about their FP use: "She is afraid that this information will get to her parents who will chase her from home" . Although only a few participants noted strong sanctions against speaking about FP to fathers, most women anticipated negative reactions and described avoiding the subject or their fathers finding out about their FP use. --- Aunts Aunts were considered trusted confidants for a variety of personal matters for women, including FP use. Participants said women would be more comfortable approaching aunts than their parents, as aunts would be more likely to speak openly: "The aunt may understand her and talk to her about the benefits and disadvantages of using family planning. The aunt will advise her right compared to her sister or mother" . Participants thought that an aunt would share both the benefits and limitations of FP openly and would ultimately recommend using a contraceptive method: "The aunt might have given her the good and the bad side of the family planning and tell her to use it because getting a kid during this time is really hard-there is no money" . Similar to mothers, aunts' recommendations were anticipated to be based on past personal experiences, such as being pressured into early sex or being made false promises by boyfriends: "The aunt will tell her that 'you may use family planning but if the boyfriend doesn't want you to use it, then he is not safe for you because a person who loves you will not want you to have a family at an early age especially when you are not financially stable' . She will give a lot of advice because Wanjiku approached her knowing she is a good person and will set an example to her. " Aunts' impartiality was deemed valuable in learning benefits and limitations to FP when women make their own decisions about using FP. Similar to other adults in the family, comfort with approaching aunts was connected with how close women were to their aunts, and perceived judgement: "It is not easy to approach a grown up and open up because questions will rise up and she might be afraid of the aunt asking so many of them like how many friends she has or where she goes for parties" . One woman said it isn't uncommon to use a cover story of a friend wanting information on FP to approach aunts about FP rather than asking directly about their own circumstances. Despite anticipating being asked many personal questions in the pursuit of knowledge or advice about FP from an aunt, this participant noted that women might still go to their aunts for advice because "[the aunt] has a good family and [a woman] would want to be like her" . --- Partners Although consulting family members on FP provided women advice from trusted sources, nearly all women described partners as key decision makers. Many women also felt partners should understand each other which was connected to the expectations of healthy relationships: --- "Relationships are all about understanding each other. If the boyfriend loves her, he should then be able to understand Wanjiku [wanting to use FP]. That doesn't mean she has to do stuff and not tell the boyfriend-he should be understanding. " Several women anticipated that their partner would oppose a decision to use FP for various reasons. One woman described the general imbalance in decision making power in relationships with men when it came to using FP: "Some husbands think they are the only ones who can make decisions in the home. A woman has no right to talk" . One man linked this imbalance specifically to FP where "[a woman using FP] will depend on what the boyfriend wants at that particular time" . Some women anticipated opposition from partners about using specific FP methods and suggested that a woman "should ask her boyfriend to use a condom, but if he doesn't agree, she should use pills to avoid having children at an early age" . Other women described using discreet modern methods, such as the pill, but claim to use traditional methods when asked about their method use: "In such a case where women are not allowed to use family planning, a wise woman will use it and then say she is using the safe-day method when confronted" . Partners and other KIs agreed that a woman will likely use FP in secret if her partner does not agree to use a visible method. Many women, partners and KIs described a partner's concerns about the possible side effects of FP, in particular about FP's potential impact on a woman's future fertility where one KI said, "if [a partner] finds out that it is Wanjiku's fault [for not becoming pregnant because she took] family planning for a long time, she may lose her marriage" . A partner linked the concern about future fertility to societal values where "in the African culture, people are termed to be wealthy according to the size of the family they have; the larger the family, the wealthier they consider you" . Participants also described partner's concern about FP's side effects on the woman's body where one woman said "[partners] will not support [using FP] and they say family planning tampers with a woman's body" . Similarly, a partner remarked: --- "Men tend to think that family planning changes the woman's body and that reduces the man's sexual desires. There is a way in which it affects the man. They say the woman feels cold during intercourse and that affects the man sexually. " Women described that using FP could indicate a lack of trust in the relationship or might be perceived by partners as a license to have sex with multiple men. One woman said, "so, when [women] use family planning, they [partners] see a woman who is a whore, or who sleeps with many men and doesn't want to be caught" . This perception creates barriers for women to negotiate FP use transparently with their partners, because "even telling [a partner] to use one [condom] might result in them asking if the women think they are being unfaithful and this might result in arguments" . Thus, women often described partners approving of FP use during marriage as a means of birth spacing, rather than a safeguard during premarital sex. The risk was even greater if women failed to share their usage or chose not to consult their partner, to the point of being outed to community elders as deviants or being positioned as unfaithful: "Some men end up reporting their wives to the church pastors if they find out they are using family planning against their wish then the pastor calls the wives and questions her as to why she is using family planning and why she didn't tell the husband about it. " While partners were identified as very important to talk to in the final decision making on FP use, many women also suggested speaking to other people in their social network about what methods to consider, such as friends, their mothers or a healthcare worker. Where families provided advice to avoid shame in FP use and partners were important decision makers in FP, close friends were important in hearing others' experiences with various FP methods. --- Friends While women's partners were often involved in the decision on FP use, most women also sought out emotional support and perspectives from their close friends. Friends were seen as being in similar situations, sharing and discussing personal experience in using FP methods were valued: "She is free with her [friend], they are of the same age and they can reason together. Secondly, she is someone she can lean on and maybe her friend has told her about family planning" . Women described their friends as close confidants with whom they would be comfortable talking about FP with, "you know, a girl has two friends whom she shares everything with" . When women established trust with their friend, women felt that friends could speak to the advantages and obstacles of both obtaining and using FP. Although most participants suggested that friends are trusted sources to confide in about FP use, one woman recognized that friends might gossip and anticipated being vulnerable to judgments of promiscuity: "Wanjiku should avoid telling friends whom she doesn't trust because they will gossip about her with other people" . Conversations with friends about FP were ongoing and often encapsulated the multiple choices women had to make regarding if, when and how to use FP: --- "So this is what she [friend] would say: 'Why do you want to use it? It's a good idea but you should know that each and every method has its own consequences. Because the pill was not so good for you. You told me before. I will tell you to try the injection. If it's not good, try the lower period of time [3 month injection]. If it's not good, try another method or go for advice from a doctor and try another good method. '" Participants were divided on whether friends would recommend FP to young women. This division was largely based on the fear that women might change their mind and want to have children in the near future while still using long-term methods: "[A young woman] might decide to use an injection that lasts for a year then come across a serious man who wants to have a child immediately and Wanjiku fails to have them because of the 1 year injection she has on her. That's why [a friend] will suggest the one for three months" . Due to this concern about future fertility, a couple of women said that friends might advise having a child before using FP: "[A friend] might ask her why she wants to use family planning-she doesn't have children and that she ought to have waited" . One key influencer similarly suggested that a friend would tell a woman that, "she has to get a child first and after the child, she can decide to use family planning" . While our findings are divided on whether these friends would recommend FP use, most women said their friends would refer women to visit a doctor for accurate and tailored information on which FP methods to use. --- Healthcare providers Whereas women sought emotional support from parents, partners and friends, they turned to healthcare providers as credible and confidential sources for information on FP. All participants expressed how doctors are largely a trusted source of information since "they have the best advice for her that she can't doubt" . One woman similarly said, "She trusts the doctor because I know that once you get to the doctor, the conversation and information is confidential" . Another woman said that trusting a doctor was also based in the hospital or clinic setting which would preserve their privacy: "When you are in a hospital no one knows you or knows where you come from, you are always comfortable to share any information or seek any information because you know that there is no way that person will connect to where you come from or meet anybody you know" . This sense of privacy was the main reason doctors were identified as a trusted source of information. A few participants anticipated being questioned or judged by HCPs about using FP on the basis of their age or marital status. Adolescents faced doctor's bias about early sex which would increase barriers to accessing FP: "With injections, the doctor may ask why a small child is going for family planning. You do know how the society we live in is" . These biases extend to the number of children they have: "The doctor needs to ask 'why do you want to use the method. And how old are you? Do you have a child? And are you sure-hundred percent-you need to start using family planning methods?'" . A few women anticipated that women who are not married or who do not yet have children would be recommended short-term non-hormonal methods: "I think the doctor would advise her to use different drugs if she is married and others if she is not married. If she has children she will be given different drugs and if she is yet to have children she will be advised to use condoms" . One woman also suggested that HCPs could hold biases that women might want to access FP to cheat on their husbands, "[The doctor] might have advised her to sexually stick to one man after giving her the family planning" . What this woman said echoed what others mentioned about their partners concerned with their possible infidelity, which, in turn, is suggestive of a larger system of norms connecting use of FP and infidelity that expands beyond the couple. While most women identified doctors or other healthcare workers as supports in accessing FP, a few had reservations about whether healthcare workers might act as gatekeepers and pose as potential barriers to accessing FP. --- Discussion We drew on 40 interviews with women and their key influencers in peri-urban Nairobi. Women reported seeking support and information with a variety of key influencers largely including mothers, partners, aunts, friends and HCPs, and discussed how decision making about FP was sometimes shared with these key influencers and was sometimes hidden. Other studies have underscored how women's social networks are the primary source of information on FP in Nairobi, where key influencers' perceptions about FP heavily influence the FP decisions women make [9, 13-16, 18, 28], and shape whether women can access the resources to visit clinics or pharmacies to seek FP [38][39][40][41]. Elsewhere, we show how COVID-19 further entrenched the reliance on key influencers. Our findings build on this literature on how social networks affect women's health and to uncover how women navigate norms around FP within their social networks to gather information to make a decision on using FP. Trust and secrecy were central for women in deciding who to speak with about using FP. Although women sought information from multiple sources before making a decision about FP use, they chose to consult those they trusted most to confide their FP use to within their social network. Trust was critical, as women wanted to keep their FP use secret to avoid social sanctions from, for instance, their neighbours or fathers. Women described trusting close female friends and relatives more than men in their social circles: Mothers were a particularly important source of information on how to maintain the secrecy of their FP use. Trust and comfort in discussing sexual health topics between mothers with their daughters is a common theme in other studies [30,42,43]. Our findings are in line with Wamoyi and colleagues who linked trust in speaking to mothers about sexual health matters to a mother's ability to offer advice based on their own personal sexual or reproductive health experiences [44]. Similar to our findings, other studies have also described fathers as the least accessible parent for women, describing father's negative reactions to discussing FP as a barrier for women in both seeking information about FP and using FP [30,44]. We found a few young women anticipated a father's reaction would be violent if FP was discussed, underscoring the uncertainty that women can face in finding supporters of FP use in their social networks. The acceptability of speaking to mothers but not fathers about FP reflects gendered norms about who it is appropriate to speak with about sexual health by young women [9,41,44]. To navigate the possibility of negative reactions with other family members, and where women are uncertain about the trustworthiness of a key influencer , they might begin by describing the situation of a friend before disclosing their own FP use. This is particularly salient for single women who face additional stigma from using FP as compared to partnered women, who experience other forms of stigma and barriers to contraception use [45][46][47][48]. We found that some partners opposed FP as it is associated with infidelity, as seen in other studies [9,32,49]. While other research has found that men, irrespective of their knowledge on FP, want to be involved in the decision of FP within relationships [49,50], our findings provide further evidence that women anticipate partners to oppose FP use, while also believing that women should talk to their partners about their FP use. In anticipating opposition from partners, some participants suggested that women should use FP irrespective if their partner disagreed. Women advising others to use FP regardless of their partner's opposition, suggests a shift in norms within peri-urban wards in Nairobi that prioritizes a women's FP decision over a partner's preference as FP becomes more widely used [1,51]. However, participants also discussed the burden of secrecy, including the fear that partners or key influencers might tell others in the community about their FP use. Many women identified HCPs as key sources of knowledge and information about FP, describing HCPs as the most confidential option for accessing reliable, accurate information about FP. However, young women in Sub-Saharan Africa have limited youth-friendly FP services which increase barriers to FP access [16,52], where existing barriers have been exasperated and additional barriers were reported during the COVID-19 pandemic [36]. HCPs acting as gatekeepers to FP access has been documented for both unmarried and married women, where accessing FP can be restricted by HCPs due to woman's age or marital status as a result of HCPs being influenced by the norms within the community they serve [16,34,35,53]. Women share their experiences with HCPs within their social networks to warn other women navigating the normative context around FP, resulting in women not solely relying on HCP, but rather accessing or confirming information about FP from their friends, who are trusted sources [9,49]. While women also describe the support they anticipate from friends as mixed, they highlight the importance of sharing anecdotal information or experiences with their friends to make informed decisions about FP. Navigating various sources of information and avoiding shame-both for women and their families-underscored the important role of friends and healthcare workers to provide judgement-free, accurate information. While accessing information about FP from key influencers is important to women, they are thus exposed to the norms and misconceptions perpetuated in their normative context about FP before they make their final decision on using FP. This study has several limitations. While our findings provide insights into the people women trust and discuss FP with, as well the fears and concerns women have about these conversations, the findings in this paper cannot be generalized and do not represent the experiences of all young women living in these wards in Nairobi. The sample size of this study was not large enough to explore differences by age, marital status or other demographic characteristics. All interviews were conducted by phone due to the COVID-19 pandemic, which may have affected the information participants felt comfortable sharing. However, especially during the COVID-19 setting, phone based interviews were advantageous to prevent the spread of the virus and evidence has found that participants might find this mode more convenient to participate in the study [54]. Nonetheless, this study fills a gap in the literature on how young women in periurban areas in Nairobi have navigated their social networks and normative context to access information on FP which influences their health and FP decision making. Our findings have several implications for policy and practice on FP in Kenya. First, the role of key influencers should be central in the development of interventions to improve the uptake of FP or change social norms about FP use. The role of key influencers is ongoing, requires trust, many conversations, and different levels of secrecy and disclosure about FP. FP interventions that include women's social networks should focus on the relational dynamics between women and their key influencers, by considering the dynamics of secrecy, trust, and emotional closeness that mediate who women talk to about FP in the context of changing norms and addressing the barriers to FP. Such efforts should not be one-off, or only focused on education or awareness raising activities with key influencers, but engage with the relational context and ongoing nature of these conversations. Secondly, our findings about the social norms held by HCP suggests the need for further training to change norms that HCP hold, in particular about why unmarried women in particular access FP. Thirdly, involving men in FP interventions should include efforts to address harmful norms and attitudes about FP. Partners and parents are key influencers in women's decision to use FP, where negative norms and attitudes towards FP might result in harm to women and low uptake of FP. Finally, future research could explore which relational spaces are most effective to transmit accurate information to women deciding on whether or not to use FP and further explore the norms held by key influencers. In particular, longitudinal qualitative studies would be instructive in understanding the ongoing conversations women have with key influencers in their social networks and how they navigate questions of shame and secrecy as they make decisions about FP. --- Conclusion Drawing on data from 16 young women, 10 partners and 14 key influencers in Nairobi, we found that women drew on their social networks as primary sources of information on FP therein navigating their normative context to find support from mothers, partners, aunts, friends and healthcare workers. This study shows how feelings of trust, a desire of secrecy, and a need for FP information shaped how women chose to speak to multiple people in their social networks based on the type of support they are seeking for their decision on using FP. We find that the process of navigating social circles for trusted people to discuss FP with is an ongoing process, where women seek people who will keep their FP use secret to avoid shame and sanctions. These findings highlight the importance of FP programmes to connect with women's social networks to engage key influencers and to share accurate FP information through women's social networks. Such efforts could be important in reducing shame and stigma associated with FP and improving access to information about FP. --- --- Abbreviations --- --- Additional file 1. Participant characteristics. Additional file 2. Vignette Interview Tool. Author contributions BC, KK and AB were responsible for the conceptualization and design of the original study with contributions from AZ, RH, AS, CG and KG. AS, CO, KG was responsible for the overall supervision of the study. RH, AB, AZ and BC were responsible for data quality. AZ, AS and KG were responsible for data analysis and interpretation. AZ, AB and KG drafted the manuscript. All authors read, reviewed and approved the final manuscript. --- --- --- Competing interests The authors declare they have no competing interests. • fast, convenient online submission • thorough peer review by experienced researchers in your field • rapid publication on acceptance • support for research data, including large and complex data types • gold Open Access which fosters wider collaboration and increased citations maximum visibility for your research: over 100M website views per year --- • At BMC, research is always in progress. --- Learn more biomedcentral.com/submissions Ready to submit your research Ready to submit your research ? Choose BMC and benefit from: ? Choose BMC and benefit from: ---

Background Contraceptive use among young women in Nairobi remains low despite high general knowledge of family planning (FP) methods. This paper draws on social norms theory to explore the role of key influencers (partners, parents and friends) in women's FP use and how women anticipate normative reactions or sanctions. Methods A qualitative study with 16 women, 10 men and 14 key influencers across 7 peri-urban wards in Nairobi, Kenya. Interviews were conducted during the COVID-19 pandemic in 2020 by phone. A thematic analysis was conducted.Women identified parents, specifically mothers, aunts, partners, friends and healthcare workers as key influencers on FP. Their interactions with these key influencers varied based on trust, the information they needed about FP, and whether they perceived a key influencer to perpetuate or challenge existing social norms on FP. Mothers were perceived to understand the social risks of using FP and thus could advise on discreet FP use, and aunts were trusted and approachable sources to impartially describe the benefits and drawbacks of FP. Although women identified partners as key FP decision makers, they were cognisant of possible power imbalances affecting a final FP choice.Opportunities to design and deliver network-level interventions which seek to engage with social norms surrounding FP in order to challenge misconceptions and misinformation among key influencers should be explored. Intervention design should consider dynamics of secrecy, trust and emotional closeness that mediate discussions of FP to address changing norms. Further training to change norms held by healthcare providers about why women, in particular unmarried young women, access FP should be provided to reduce barriers for FP access.

2 A. Jiménez-Iglesias et al. Perceptions of social support from different contexts vary according to age and gender. Girls perceive higher friend support, teacher support and classmate support than boys . In addition, younger adolescents perceive similarly important parental and friend support and classmate and teacher support , and according to other research maternal support is the main source of support followed by paternal, classmate and teacher support . In contrast, older adolescents perceive friend support as more important than parental support and classmate support as similarly important to parental support , whereas they perceive lower teacher support. This decrease of teacher support is probably due to the transition from primary to secondary school . Regarding the differences between parental and friend support, during adolescence parental support decreases and friend support increases, finally reaching similar levels . This could be related to the decrease of parental influence and the increase of friend influence during adolescence, although both are similarly relevant towards late adolescence . In addition, substance use increases during adolescence , it is higher in older than in younger adolescents , and boys' substance use increases more than girls' substance use along adolescence . Regarding well-being, girls and older adolescents show lower levels of well-being . Perceived social support is associated with child and adolescent well-being and it seems that the association between social support and well-being increases with age, being greater in girls than in boys . In contrast, poor social support is a risk factor for adolescent mental health problems . --- Family support, adolescent substance use and well-being Parental support is the source of support most strongly associated with mental health, particularly with positive life satisfaction , it is considered the best indicator of lower emotional problems throughout adolescence and it seems to influence the effect of friend support. Specifically, in adolescents with higher parental support, friend support had a slightly positive effect, whereas in adolescents with lower parental support, friend support had a negative effect . Family support positively influences adolescents' subjective well-being , such as life satisfaction . Similarly, perceived support from adult family members is associated with fewer depressive symptoms and parental support is associated with fewer emotional symptoms . Moreover, parental support is negatively related to substance use and maternal support is associated with lower substance use . In fact, substance use is lower in boys and girls who had caring and supportive relationships in their families during childhood, and cohesive family context throughout adolescence and emerging adulthood . --- Friend support, adolescent substance use and well-being Friend support positively influences adolescents' subjective well-being , such as life satisfaction . However, others studies have found the contrary, showing that friend support did not influence on life satisfaction . In the case of substance use, it has been found that friend support is not associated with substance use , and in contrast that peer support is positively related to substance use since peer group may favor risk behavior and have more positive substance use attitudes . --- School support, adolescent substance use and well-being Concerning school, classmate support has been associated with fewer emotional symptoms , lower internalizing behavior and positive life satisfaction, and although teacher support did not associate with these variables, it did however with lower externalizing behavior and it indirectly influenced life satisfaction mediated by satisfaction with school . In addition, other studies have found that perceived support from adults in the school context is not associated with depressive symptoms, probably because adolescents perceive adults at school as sources of support for academic issues and not for emotional issues . Possibly for similar reasons, in a study by Leme et al. , teacher support did not influence adolescents' subjective well-being. However, other studies have found that teacher support is positively Social Support, Substance Use and Well-Being 3 associated with subjective well-being and low teacher support, among others school-related aspects, implies low subjective and social well-being . In fact, a meta-analysis found that support from teachers and school personnel had the highest association with well-being, followed by family support, while friend support and other support had the lowest association . In addition, it has been found that adolescents with higher teacher support perceive their schools as having a more respectful and healthy climate and this promotes lower substance use as well as higher social belonging and fewer depressive symptoms . --- Social support in Spain and Portugal Social support seems to be an important factor for adolescent development and it is therefore of great interest to know how perceived support in different contexts, such as family, school and peers, contributes to their development in two similar countries, like Spain and Portugal. In general, Portugal and Spain share many cultural and political similarities, which make it relevant to carry out this study in both countries. For example, Spain and Portugal are two of the European countries that assign less money to family-related policies ; the education system is similar in both countries, Portuguese and Spanish adolescents' perception about school generates concern and the model for the provision of school health services is community-based in both Spain and Portugal . Additionally, adolescents from Spain and Portugal show a positive perception of their families, parental support and good relationships, are generally involved in unproblematic peer group, as well as being satisfied with aspects of their school context . --- Aims and hypotheses The aim of this study was to analyze the role of social support from the main developmental contexts in adolescent substance use and well-being in Portugal and Spain. Analyses were performed after deleting the effects of gender and age since, as has been indicated above, these demographic variables are related to social support, substance use and well-being and could affect the relationships between them. It was expected that all the sources of social support would be relevant for adolescent substance use and well-being, especially family support, and the social support from the main developmental contexts would be particularly important for adolescent well-being. Additionally, similar results were expected between Spain and Portugal due to similarities in both countries. --- Method --- --- Measures The measures used in this study come from the 2014 edition of the HBSC questionnaire. In order to ensure that the same variables are measured in all countries, the HBSC study recommends carrying out a specific and critical translation process of the questionnaire: first, the measures are translated from English to national languages ; second, they are back-translated into English by a different translator; thirdly, the backtranslations are reviewed by the national teams; and finally, the back translated measures are reviewed by the Translation Group Reviewer of the HBSC study --- Procedure --- Data collection The study was approved by the Ethical Research Committee of the University of Seville and the Ethical Commission of the Hospital S. João do Porto and was authorized by the Portuguese Ministry of Education and the Spanish Ministry of Health, Social Services and Equality . The data collection in both Portugal and Spain was done through an online questionnaire that fulfilled the requirements of the HBSC study : the adolescents must answer the questionnaire themselves; the anonymity and confidentiality of their answers must be guaranteed; and the questionnaires must be administered within the school context . --- Statistical analysis The statistical analyses were performed using the IBM SPSS Statistics 23 program and were carried out separately for Portugal and Spain to analyze differences between both countries. General Linear Models were used in order to control the effect of gender and age on the substance use and well-being variables and to save the unstandardized residual dependent variable. Following this, General Linear Models were performed to examine the role of social support in unstandardized residual variables of substance use and well-being after the effect of gender and age had been eliminated. R 2 values were used to inform about the relevance of the models, specifically using Cohen's criteria , the relevance was considered negligible from 0 to .019, small from .02 to .129, medium from .13 to .259, and large from .26 or greater. Partial eta squared values were utilized to analyze the effect size of each variable, taking into account that values were considered negligible from 0 to .009, small from .01 to .059, medium from .06 to .149, and large from .15 or greater . --- Results General Linear Models of gender and age on the substance use variables were significant and with small relevance in Portugal and Spain for tobacco use = 61.620, p < .001, R 2 = .032; Spain: F = 212.521, p < .001, R 2 = .032) and for alcohol use = 64.083, p < .001, R 2 = .033; Spain: F = 242.938, p < .001, R 2 = .037). Similarly, General Linear Models of gender and age on the well-being variables were also significant with small relevance in Portugal and Spain for life satisfaction = 87.999, p < .001, R 2 = .046; Spain = 484.230, p < .001, R 2 = .073) and for healthrelated quality of life = 230.582, p < .001, R 2 = .111; Spain: F = 770.190, p < .001, R 2 = .122). On the other hand, General Linear Models used to analyze the role of social support in unstandardized residual variables of substance use and well-being after the effect of gender and age had been eliminated showed similar results in Spain and Portugal. The model of social support from developmental contexts on tobacco use was significant and with small relevance in Portugal = 29.379, p < .001, R 2 = .023). All social support variables, except classmate support, were significant, but the effect size was only noticeable for family support with higher values favoring less tobacco use. On the contrary, in Spain the model was significant but the effect size did not reach a noticeable value = 59.086, p < .001, R 2 = .015). These results are shown in table 2. Regarding alcohol use , the models were significant, but the effect sizes were negligible in Portugal = 12.724, p < .001, R 2 = .010) and in Spain = 44.652, p < .001, R 2 = .011). Concerning the model of social support from developmental contexts on life satisfaction , as is shown in table 4, in Portugal it was significant with medium relevance = 200.255, p < .001, R 2 = .140). All the social support variables were significant and the effect sizes were small for family support , teacher support and classmate support , and the effect size was negligible for friend support . In Spain, this model was significant with medium relevance = 717.031, p < .001, R 2 = .151). Again, all the social support variables were significant, but the effect sizes were small only for family support and friend support , whereas for teacher support and classmate support they were negligible. With respect to health-related quality of life, higher values of social support implied higher health-related quality of life. In Portugal, the model was significant with large effect size = 465.298, p < .001, R 2 = .274). The social support variables were also significant and the effect sizes were medium for family support and small for teacher support , classmate support and friend support . Similarly, in Spain the model was significant with medium relevance = 1078.219, p < .001, R 2 = .228) and all the social support variables were significant with small effect size: family support , teacher support , classmate support and friend support . The results are shown in table 5. --- Discussion The purpose of this study was to know what sources of social support from the main developmental contexts were relevant for substance use and well-being in Portuguese and Spanish adolescents. Analyses were performed after deleting the effect of gender and age. The results of this study partially agreed with its hypotheses. Social support variables were not relevant for substance use, with the exception of family support for tobacco use in Portugal, showing that higher values of parental support imply less substance use, as confirmed by previous studies . These results could be due to the fact that although different developmental contexts are analyzed, the social support variable is only one aspect of each context and is probably not as relevant to substance use as it is for well-being. As was found by Branstetter et al. , it would have been important to analyze different aspects of each context and not only one aspect, such as social support in the case of our study. Regarding friends, it is very likely that friends' substance use and the peer pressure to use substances have a clearer role in predicting adolescent substance use than friend support. Therefore, the results of this study do not prove that the developmental contexts analyzed are In contrast, social support was relevant for wellbeing, with higher values of social support implying higher adolescent well-being in both countries. Specifically, family support, teacher support and classmate support were especially relevant for higher life satisfaction in Portugal, whereas in Spain, family support and friend support were more important for life satisfaction. All the social support variables were relevant for health-related quality of life in Portugal and in Spain. Therefore, family support is a key factor for well-being in Portuguese and Spanish adolescents. In fact, parental support is the dimension most related to mental health, mainly life satisfaction , as well as to lower emotional problems during adolescence . It has been also found that family support is positively associated with adolescents' subjective well-being in general , and specifically with adolescent life satisfaction . In addition, teacher support is relevant for life satisfaction in Portugal and for health-related quality of life in both countries, whereas friend support is relevant for life satisfaction in Spain and for healthrelated quality of life in both countries. Previous studies have found contradictory results regarding support from teachers and friends, with some studies finding that friend support and teacher support are positively associated with well-being, whereas others have not shown this association neither with friend support nor with teacher support . These results could explain that teacher and friend support are more relevant in Spain or Portugal depending on the well-being variable. When the relationship between social support and health-related quality of life is analyzed in this study, both teacher and friend support are relevant in both countries. This may be because health-related quality life is a more global measure of well-being than life satisfaction. The same can happen with classmate support, because this variable, as teacher support, is more important for life satisfaction in Portugal and for health-related quality of life in both countries. Therefore support from classmates, as previous studies have found, is relevant for positive well-being , especially in Portugal. These results also suggest that school-related social support is more relevant for adolescent well-being in Portugal than in Spain. Additionally, the support of classmates in Portugal behaves similarly to the support of friends in Spain. A possible explanation is that in Spain the classmate group habitually changes every two years, whereas in Portugal the classmate group often stays together through almost all the compulsory education making it more likely that classmates are also friends and more important for adolescents in Portugal than in Spain. Nevertheless, it would be interesting to do an in-depth analysis in future research of the role of classmates and friends in Spanish and Portuguese adolescents. Furthermore, these results contribute to reflections on concerns about the education system in Spain and Portugal, as well as the data of the last HBSC international report regarding Portuguese and Spanish adolescents' perception about school compared with adolescents from other countries. In this report for . In general, as was expected taking into account cultural and political similarities, the results of this study are very similar in Portugal and Spain, probably because Spanish and Portuguese adolescents perceive their family context, peer groups and school context similarly . On the other hand, it is indispensable to indicate some limitations of this study when considering the results, such as that the HBSC study is a cross-sectional study that does not allow for establishing causal relationships. Others limitations include the fact that only one aspect, and not more dimensions, about the relationships in each context is studied and that it is examined as it is perceived by adolescents and not by other members of each context. In conclusion, this study shows that social support is more relevant for adolescent well-being than for adolescent substance use, as well as that social support in each context, mainly family context, is important for adolescent health and well-being, which must be taken into account in interventions to promote adolescent health in Portugal and in Spain. Specifically, interventions in schools must be directed towards improving the education system considering the concerns based on adolescents' perception of school . Additionally, these interventions must consider that school health promotion is one of the priorities for the school context, however the community-based model, existing in Portuguese and Spanish schools, does not always have as a main priority the school health promotion and the integration and acceptance of the health system in schools could be difficult with this model , and therefore it would be necessary to overcome these limitations. Regarding interventions with families, since the economic benefits for family-related policies in Spain and Portugal are scarce and family context was found to be the most important for adolescents in this study, it is necessary to provide more resources for Spanish and Portuguese families and, in general, to promote public policies with a family perspective across Europe , which ensure quality contexts for all families and adolescents.

Family, school and community (peers, leisure, and neighborhood) are primary developmental contexts for adolescents. Research and intervention in these contexts are very important to prevent externalized and internalized problems as well as to promote health and well-being in these contexts (Stattin & Kerr, 2009). For example, positive parent-child relationships result in lower substance use (Johnson, McBride, Hopkins, & Pepper, 2014), such as alcohol and tobacco use (Piko & Balázs, 2012). In a qualitative study by Navarro et al. (2017), relationships with family and friends were considered to be the most important for well-being, confirmed by other studies indicating that family and peer relationships have a positive influence on adolescent well-being (Tomé, Matos, Camacho, Simões, & Diniz, 2012;Williams & Anthony, 2015). Additionally, a positive school climate promotes healthy development, with lower drug use and higher mental health (LaRusso, Romer, & Selman, 2008).This study examines family, school and peer contexts. Specifically, it analyses the perceived social support from these developmental contexts and the contribution of the family, teachers, classmates and friends support in adolescent substance use and well-being. Social support is a relevant aspect of each context, which in general refers to the help and emotional support that adolescents may have from different sources, such as family, friends, teachers or classmates.

Introduction The health and wellbeing benefits of green exercise In the past three decades, studies have consistently demonstrated that human-nature interactions provide a broad range of health and wellbeing benefits. Different pathways have been proposed to link nature contact to people's physical and psychological health, involving air quality/heat modulation, physical activity, social cohesion, and stress reduction [1,2]. A 2016 review by the World Health Organization demonstrated that natural environments contribute to reducing morbidity and mortality among urban residents through these pathways [3]. In particular, through intertwining and synergic benefits of nature contact and physical activity, green exercise has been shown to support health and wellbeing by eliciting desirable psychological, physiological, and social effects [4]. In particular, green exercise is associated with short-term benefits such as improved psychological states [5,6], reduced psychophysiological stress [5,7], and facilitation of social interactions [8]. Moreover, when performed regularly, green exercise can elicit long-lasting benefits such as higher levels of self-rated health [9,10] and satisfaction with life [9,11], as well as strengthened social support [12,13]. Different review studies corroborated the added health and wellbeing benefits of green exercise compared to physical activity indoors or in urban settings, though they also highlighted limitation within this research field, including among others the fact that the large majority of studies focus on Western populations [14][15][16]. On the other hand, evidence exists indicating that the health and wellbeing benefits of nature contact and green exercise can apply to people from various cultures and ethnicities, providing a protective factor for immigrant populations [17]. In light of this, in recent years, the concept of "nature-based integration" has been proposed, especially across Nordic countries, as an efficient and cost-effective way for better integration of immigrants [18]. The research on the health and wellbeing benefits of green exercise among immigrant population in the Nordic context, however, is still in its infancy. In particular, there is a need to understand the way in which immigrants from the European Economic Area experience green exercise, and how this contributes to their health and wellbeing. --- Green exercise in the norwegian context In the Nordic countries, green exercise is culturally valued and embedded within various layers of the societal system, including the educational and sport-related arenas [19]. Particularly in Norway, there is a vibrant tradition for green exercise, known as "friluftsliv". This unique cultural phenomenon, prevalent in all Scandinavian countries, has roots in a historical lifestyle and means of transportation. It has evolved into a traditional leisure practice where being in and moving through nature using simple means is a core motivational element [20]. Today, green exercise in Norway is largely popular, also supported by the fact that 61% of the population has access to safe recreational areas and natural environment [21]. Moreover, green exercise practice is reinforced by policies granting access to natural environments and promoting the practice within compulsory school and health institutions [22]. A 2016 study showed that 61% of Norwegians engaged in green exercise during a regular week [23]. Walks and hikes in the woods or mountains are especially popular, with water-related activities and winter activities being popular seasonal activities [24]. In an immigration context, studies show that immigrants residing in Norway generally appreciate and participate in green exercise [25][26][27]. For instance, a qualitative study on female immigrants from various backgrounds residing in Norway revealed a complex use and perception of natural environments for recreation, physical activity, and social purposes, generally supporting the women's mental health [26]. On the other hand, immigrants were found to often experience barriers to the practice of green exercise, including lack of knowledge on where and how to practice it, challenges in understanding information on advertised opportunities, lack of time, and fatigue [27]. A case study also found that, compared to the non-immigrant population, immigrants living within Oslo metropolitan area had less daily access to areas that can support green exercise [28]. The Norwegian Government formally acknowledged the vital role of green exercise among immigrants and prompts its promotion within its official integration strategy framework [23]. --- Green exercise and acculturation As green exercise is an important part of the Norwegian culture and way of life, the practice of this activity among immigrants can be seen under the prism of acculturation. A widely used definition of acculturation refers to "the process of cultural and psychological change that takes place as a result of contact between cultural groups and their individual members" [29]. Acculturation can take multiple and dynamic paths [30]. Immigrants may adopt aspects of the culture of the host country in some spheres of their lives, but not in others, or adapt aspects of the host couture to their own. Acculturation's path may be influenced by the specific reasons for migration, how immigrant groups are received in the host country, and personal resources. Differences among groups of immigrants with different backgrounds have been highlighted [27,31] and, with the few existing studies mainly focusing on immigrants from non-Western countries, a knowledge gap remains with respect to the practice of green exercise and its significance to health and wellbeing among intra-EEA immigrants. --- EEA migration in the nordic countries: the case of italian immigrants in Norway While immigrants from Asia, Africa or Latin America account altogether for half of the immigrant population in Nordic countries, the remaining part is predominantly from countries within the EEA [32]. Among these, in 2023, Norway counted 6,112 immigrants of Italian origins , of which 5,700 were first-generation immigrants [33]. Although a relatively small group, it should be considered that Italian migration to Norway has been steadily increasing since the EEA agreement in 1994 and has tripled since the economic crisis in 2008 [33]. A peculiarity of this group is that, compared to other immigrant groups, most of Italian immigrants in Norway have a higher educational level and are employed in high-income occupations. For instance, in 2019, it was estimated that 61% of Italian immigrants in Norway had a university degree, with 17% possessing a Doctoral degree [34] -by comparison, the proportion of individuals with a university degree in Italy and Norway in the same year was 20% and 33%, respectively [35,36]. However, many Italian immigrants in Norway work in less stable and more menial jobs [37]. Although among the Italian immigrants in Norway there is a considerably larger prevalence of men than women, the proportion of female immigrants, including women moving alone for occupational or study purposes, has been increasing in the past decade [37]. These trends are largely in line with immigration trends from other Southern-European countries, such as Spain and Greece [32]. --- Health and wellbeing among italian immigrants in Norway Immigrants are often at higher risk for lower quality of life than the host country's general population [38]. In the Norwegian context, a 2016 national survey among immigrants found that, compared to the non-immigrant population, immigrants often reported more frequent mental health challenges, lower self-rated health, and lower life satisfaction [39,40]. Such health challenges have been associated with poor language proficiency, unfamiliarity with the health system, or limited social networks [41][42][43]. Moreover, differently than in the nonimmigrant population, for which life satisfaction was primarily predicted by sociodemographic factors , among immigrants life satisfaction was primarily predicted by immigration-related factors, such as having a partner living abroad and experiencing discrimination [40,44]. Relatively to the Italian immigrants in Norway, a recent study found equivalent levels of self-rated health as compared to both the general Norwegian and Italian populations [34]. However, considering the higher socio-economic status of this group [45,46], which is generally associated with better health, this finding indicate the presence of some health-related challenges. Indeed, Italian immigrants in Norway were found to experience lower levels of health literacy [47] as well as challenges in navigating the Norwegian social norms and systems, leading to barriers in using the health system and establishing meaningful social relationships [46]. On the other hand, many reported to have increased their physical activity levels after moving to Norway [25]. In particular, 64% of the Italian immigrants in Norway practiced some green exercise within a regular week, a prevalence that is equivalent to the Norwegians' [25]. This contrasts with the much lower levels of green exercise participation among Italians living in Italy, where only 25% reported to perform, regularly or occasionally, green exercise in urban settings , while 31% do it in natural environments outside the city . These patterns are likely related to the poorer availability of green exercise opportunities that characterize Italy, which is among the European countries with the lowest population-weighted surface area of natural environments that can be reached within 10 min of walking [48]. Nevertheless, this corroborates the assumption that the Italian immigrants tend to change their green exercise habits after resettling in Norway, which may contribute buffering the health and wellbeing challenges that they face. --- The present study Given the cultural and structural differences that characterize Italy and Norway concerning the practice of and opportunities for green exercise, as well as the increased green exercise participation observed among the Italian immigrants in Norway, the case of this particular migration group is of interest to gain a better understanding of green exercise and its health and wellbeing benefits in the context of migration within the Nordic countries. Furthermore, representing a case of intra-EEA migration, the focus on Italian immigrants in Norway can extend the knowledge of this underresearched group. Hence, the overarching purpose of this study was to investigate the extent to which green exercise may support health and wellbeing among Italian immigrants to Norway, as well as to explore factors that may influence this relationship. Specifically, the present study used a mixed-methods approach to provide both a broad overview of the phenomenon with generalizable findings and an in-depth understanding of the Italian immigrants' experiences and beliefs. --- Materials and methods --- Overall design The present study is part of the larger project "Mens Sana in Corpore Sano", which investigated health and healthrelated behaviours of Italian immigrants in Norway [49]. The data collection was conducted between March and May 2019 . The study adopted a convergent mixed method design [50,51]. To facilitate the integration process, the survey and the interview guide were purposefully developed based on the same topics . The quantitative and qualitative strands were conducted and analysed in parallel, and the findings of each strand presented separately [50]. The merging was done with a simultaneous bidirectional approach, using a matrix to compare the outcomes of the statistical analysis with the qualitative quotes and themes extracted from interviews [51]. Equal relevance was given to both strands, focussing on whether there was consistency between them and how the outcomes of each strand may expand the other. The initial merging frame was outlined by one author and further developed in collaboration with two other authors . The final interpretation and reporting of the integrated findings were done by discussing both qualitative and quantitative findings together on a theme-by-theme basis [50]. --- Quantitative strand --- Data and participants The survey was conducted among adult Italian immigrants residing in Norway, who spoke Italian and spent most of their childhood in Italy. Since an updated contact list of all the Italians living in Norway was not available, the survey was distributed through different channels, including invitations through the mail-list of COMITES Oslo and announcements on the Italian Embassy's newsletter, and different online groups for Italians living in Norway. Compliance with the inclusion criteria was assessed through control questions in the survey. A total of 330 people responded to the survey, of which 321 met all the above criteria. A comparison of sociodemographic variables of the sample with figures provided by Statistics Norway and the Registry of Italian Citizens Residing Abroad revealed that the sample had a larger proportion of women, mid-aged individuals, people with a higher educational level, and people living in the region of Oslo-Akershus . To enhance the sample's representativeness, the original dataset was oversampled using the ADASYN method [52] based on the expected distribution of age and education level , which also resulted in an acceptable adjustment of gender and place of residence. Details about the oversampling process and sample's characteristics are reported in a previous publication [25]. --- Instruments and Study variables The questionnaire used in the Mens Sana in Corpore Sano study included items retrieved from surveys previously conducted by professional statistical agencies in the Norwegian population. All items were translated to Italian by native speakers with expertise in health surveys. Besides contributing to higher validity of the measurements, this also allowed for comparisons with other immigrant groups or the general Norwegian population . More specifically, the items included in in this particular study were retrieved from the following surveys: I. Levekårsundersøkelsen blant personer med innvandrerbakgrunn 2016 [39]. This survey was designed and distributed by Statistics Norway to investigate the health and living conditions of immigrants from non-western countries. The survey contains many of the items included in the Levekårundesøkelsen om helse , a survey routinely conducted by Statistics Norway in the Norwegian general population [53]; II. FRIFOs aktivitetskartlegging 2012 , a survey on physical activity habits and related beliefs and motivational factors in the general Norwegian population, which was initiated by The Norwegian Outdoor Council and designed and conducted by Ipsos MMI [23]. For the present study, the following variables were used: Outcome variables. The outcome variables were health and wellbeing, operationalized as Self-rated health and Satisfaction with life , respectively. SRH was assessed through a single-item inquiring "In general, how would you rate your health?" which was rated on a 5-points liker scale . Similar instruments are commonly used in population studies as a subjective and comprehensive indicator of health, and studies have shown their validity against objective assessments of mortality [54,55]. SWL is an overarching construct that captures the affective feelings and cognitive judgments people have about the quality of their lives, which has received growing scientific attention as an indicator of wellbeing as well as immigration's overall success [40,56]. In this study, SWL was assessed through an item inquiring "Overall, how satisfied are you with your life at the moment?" which was rated on an 11-points visual scale . Both instruments were previously used in a Norwegian survey on living conditions among immigrants [39,40] as well as in other studies investigating the association of green exercise with health and wellbeing [9,10]. Primary predictor. The main predictor in this study was Green exercise, a measurement that grossly quantified the frequency with which the Italian immigrants participated in this activity, which was assessed through three items . Two items were designed to capture the extent to which the participants performed green exercise activities that are common in the Norwegian context and more generic experiences in nature. The third item provided a gross indication of the respondents' amount spent in green exercise relative to their overall weekly physical activity. A caption stated "Consider the overall time you spend doing physical activity during a regular week. How much of this time do you spend in each of the following activities:" A list of activities was then presented, including "Walking or exercising in parks, green spaces, or other natural environments". Each item was rated on a 4-points scale . The internal consistency of the measure was adequate . Control variables. Control variables were included in the analyses to assess the extent to which they may influence and explain the relationship of Green exercise with SRH and SWL. These variables, which were identified based on previous scientific literature as well as exploratory analyses, included measurements of green exercise supporting factors , sociodemographic characteristics , and acculturation . Childhood experiences and social support are known to influence people's participation in green exercises [13,57], as well as its relationship with health and wellbeing [1,4]. Childhood experiences were assessed through two items, which were similar to those used to assess Green exercise, but specifically referring to the respondents' childhood . Social support was assessed through three items relative to social facilitation for the practice of green exercise . The Internal consistency of both measurements was acceptable . Individuals' sociodemographic characteristics are known to influence health and participation in physical activity, including green exercise [34,47]. In this study, In line with previous research, Language proficiency was used as a proxy measure for acculturation [58,59]. This was assessed through a single-item inquiring "How would you rate your Norwegian-language skills?" The item was rated through a 5-pt Likert scale . --- Statistical analysis In line with previously used approaches [9,60], SRH was dichotomized as 'worse SRH' and 'better SRH' , while SWL was dichotomized as 'lower SWL' and 'higher SWL' . All variables were explored for distribution, missing data, and outliers. No missing data or extreme outliers were identified. Cronbach's alpha was calculated to assess the internal consistency of the multi-item variables . Descriptive statistics were performed and presented as means and standard deviation or frequency and percentages . Assumptions for multivariate logistic regression were preliminary assessed. All observations were independent of each other, and the sample size was deemed adequate for a multivariate analysis based on the 'rule of thumb' of at least 10-20 observations for each predictor included [61]. Multicollinearity was evaluated through the Variance Inflation Factor and linearity in the logit for the continuous variables was evaluated using the Box-Tidwell test. Additionally, exploratory bivariate regressions were conducted to evaluate the relationship of SRH or SWL with all control variables individually. For each outcome variable , two logistic regression models were performed to establish the relationship of Green Exercise with better/worse SRH and higher/lower SWL. Firstly, bivariate logistic regression was performed to establish the un-controlled relationship of Green exercise with each outcome variable. Subsequently, to assess the extent to which other factors influence the relationship of Green Exercise with the outcome variables, a multivariate model was performed including Green Exercise as a predictor whilst controlling for all other variables . The explained variance for each logistic regression model was expressed as Negelkerke's pseudo R 2 , while the effect size of the association for the individual predictors was expressed as odds ratio and 95% confidence intervals . All analyses were performed using IBM SPSS Statistics version 27.0 . Significance level was set at p < 0.005. The statistical analysis was conducted by one author and revised by a second author . --- Qualitative strand Participants Informants were recruited using snowball sampling. Inclusion criteria were the same as for the quantitative strand. The process was initiated through an announcement during a gathering of Scienze senza confini , an initiative promoted by COMITES Oslo an that aim at connecting Italian professionals living in Norway. The recruitment process aimed to represent the variation among Italians living in Norway concerning gender, age, years of permanence, and reasons for migrating. The final sample consisted of 14 participants , half of whom have lived in Norway for more than 10 years, while four had lived in Norway between 5 and 10 years and three for less than 5 years. Four were between 30 and 40 years old, eight between 41 and 50 and the remaining were between 51 and 65 years old. Three of the informants moved to Norway for study reasons, three for family reasons, two to follow their partners, and the remaining for workrelated reasons. Most of the participants lived in Oslo. --- Data collection In-depth interviews were chosen as this methodology offers the opportunity to explore a phenomenon's more thoroughly and flexibility to ask relevant follow-up questions [62]. The interview guide focused on the health and life conditions of the Italian immigrants in Norway, and particular attention was given to the Italian immigrants' attitudes towards and experiences with green exercise. The interview guide was designed by the last author , who has expertise on qualitative research and migration's health, in dialogue with the first author , who has wide expertise in green exercise as well as barriers to and the salutogenic effects of human-nature interactions. The interview guide was pilot tested on two individuals, to check for fluidity of the interviews and refine questions. No relevant adjustments were made to the interview guide after the pilot testing, hence the two pilot interviews were included in the final sample. All interviews were conducted in Italian . To better accommodate the schedule of the informants and reach residents in various parts of the country, most interviews took place via video call, at the informants' homes, or in public places . Each interview lasted 45 to 90 min. One author transcribed the interview audio files verbatim. Since the Italian community is relatively small, to ensure high privacy standards, only this author had access to the complete interview audio files and transcripts. --- Data analysis The interview data were analysed using a thematic analysis approach [63], which is coherent with the mixedmethods research design, as it facilitates communication among researchers who use different research methods [64]. In this study, we have focused on how respondents experienced green exercise and the way it influenced their health and wellbeing. After familiarising with the data, initial codes were generated using a hybrid approach of inductive and deductive coding and theme development [65]. An initial coding frame was developed based on the study's research questions and the interview guide's main themes . In the next step, inductive codes were generated directly from the text to develop the sub-themes or to identify novel themes . The final refinement of themes occurred through dialogue among three authors , alongside reiterative reading and reflections based on the literature. --- Results --- Quantitative findings Descriptive statistics for all the variables, for the overall sample as well as for the participants with worse/better SRH and lower/higher SWL, are presented in Table 2. Table 3 presents the outcomes of the logistic regressions examining the relationship of Green exercise with SRH and SWL, before and after controlling for the confounders. The bivariate logistic regression revealed a statistically significant and positive association of Green exercise with both SRH and SWL, indicating that the participants who practiced green exercise more frequently had a greater likelihood of reporting 'better SRH' and 'higher SWL. ' In the multivariate models, the relationship of Green exercise with SRH was no longer significant, indicating that the SRH's levels were better explained by the control variables. In particular, the model indicates that the respondents' Educational level and Language proficiency were significant and independent predictors of SRH, with those having the highest educational degree and those with better proficiency of the Norwegian language being more likely to report better SRH compared to those with a lower educational degree and poorer proficiency in the Norwegian language. Differently, Green exercise remained a highly significant predictor of SWL even after controlling for multiple control variables. Alongside Green exercise, Childhood experiences and Social support also were identified as significant predictors of SWL, indicating that these factors play an important and independent role within the pathways that link Green exercise to SWL. Social support showed a positive relationship with SWL, with those perceiving to have a stronger social support for green exercise being more likely to report higher SWL. On the other hand, Childhood experiences showed a negative relationship with SWL, indicating that those who had less frequent green exercise experiences during childhood were more likely to experience higher SWL. Higher Education level and Language proficiency were also significantly and positively associated with higher SWL. --- Qualitative findings From the qualitative analysis, three themes were identified, each containing two sub-themes: i. Green exercise opportunities contributing to overall satisfaction --- Green exercise opportunities contributing to overall satisfaction Appreciation of everyday nature experiences. In several interviews, it became visible that Italians living in Norway experience nature in their everyday life, which was generally appreciated. In contrast to their past life in Italy, views of nature from home or other everyday locations became a new routine in Norway. The voice of a participant depicts well how such everyday nature experiences, as opposed to more "extraordinary" nature experiences, are coloured by positive evaluations: --- "Let's say that I haven't visited much of Norway, I would like to live it a bit more because I really like it. I cannot put myself in extreme situations, but for a person coming from [a big city in Italy] the idea of having a deer coming to eat in my garden it's a unique feeling. " . Green exercise supporting health and wellbeing. The Italian immigrants reported to perceive the presence of nature in their everyday life as a factor contributing to their overall wellbeing, mainly by providing opportunities to relax and get away from daily hassles. Further, relaxing was recurrently reported as an important motive for seeking nature contact by engaging in green exercise. --- "For me, the best is finding a nice place outside, escaping the rhythm of the city […] it is priceless. It contributes very much to feeling well. The sight of this beautiful nature relaxes me a lot. It helps my wellbeing a lot. " . As an informant observed, green exercise is perceived as embedded within general strategies for promoting health in Norway. "In Italy, if you have a health problem, they put you on sick leave for a week, but here they tell you: go for a walk in the forest!" . --- Closeness to nature Feeling surrounded by nature. Another recurrent theme in the qualitative interviews was the perceived accessibility of nature in Norway compared to Italy. Accessibility to nature was described not just as shorter distances to environments where one can practice green exercise but also through the felt opportunity of feeling close to nature: "Nature, I used it also earlier [in Italy], this must be said, [here] it's not so much that we use it, we are inside it. The houses, even though you are in the city, you still are in close contact with nature. " . " --- Here I have it so close that is impossible not to perceive it, […] you basically have it inside your home. You step outside and you are in the middle of nature, you take the subway and are in Sognsvann [the entrance to a popular hiking area], you take the ferry and are on the islands. " . Tamed nature vs. Wilderness. In an interview, an informant described how the natural landscape in Italy is dominated by agricultural activities . In Norway, nature is perceived as more uncontaminated or wild, even in the vicinity of cities. These landscapes appear to have the potential to change the experience of nature when engaging in green exercise. "Let's say that here there is a more direct contact with the wilderness. I used to live in Tuscany and, even if I did bike rides, I did it among cultivated lands, environments more influenced by human activity, and instead here, with short distance to the forest and more uncontaminated and untamed nature, this changed. And I tend to enjoy it more. " . --- Embracing a new lifestyle Changing mind-set. In public discourses, Norwegian nature is primarily interpreted as a safe place, not only in practical terms but also culturally: spending time in nature is part of a core of shared norms in the Norwegian society. The Italian immigrants seem to have partially absorbed this culture, learning new forms of green exercise that are iconic in Norwegian society or spending their spare time outdoors with friends or family. One informant talked about "changing their mindset" after moving to Norway and seeing new opportunities. Activities like downhill skiing, which in Italy were seen as activities restricted to holiday periods or weekends, became part of the everyday exercise routines in Norway. --- "I had to change my way of thinking. Hence, for the second year in a raw I bought the season-pass to go skiing, because I do enjoy down-hill skiing […]. This year I even went by myself, because my children do other activities, so yes, my winter activity is down-hill skiing. " . Changing mindset regarding green exercise practice also was mentioned when informants talked about getting accustomed to being outdoors, even in more adverse weather conditions than those they used to tolerate in Italy. "Before, in Italy, if there were 10-15 degrees [above zero] I did not go out, I waited for the next day. Not here. I've learned enjoying the cold. " . Outdoors activities 'Italian Style. ' Despite embracing social norms and habits related to green exercise, some informants perceived challenges and barriers. For example, the weather is a recognised barrier that influences the Italians' participation in and attitudes towards green exercise. "We try to spend as much time as possible outdoors, with the limit of my 'Italianises' … Sleeping in a tent in winter, I wouldn't do it. Especially if it's super cold, like around 15 degrees below zero, you can forget it. " . Moreover, the social norms around the practice of green exercise are so present in Norwegian culture that it may sometimes be perceived as an imposition, eliciting negative evaluations. "Cross-country skiing, I was forced to do it. Yes, yes, [I do cross-country skiing] but only when there is nice weather and not if there are 20 degrees below zero. For instance, Sunday I did 20 km, at my own pace, there was nice weather, then yes. But when it's something you do just because you must, then no. " . --- Discussions --- Significance of green exercise for health and wellbeing The logistic regression demonstrated the importance of Green exercise as a factor associated with higher SWL and, to a lesser extent, SRH among the Italian immigrants. The in-depth interviews also support that everyday experience of nature and green exercise is perceived as an important contributor to wellbeing and overall satisfaction, rather than physical health, primarily through relaxation and stress reduction. The explained variance for the association of Green exercise with SRH was relatively low . The inclusion of the control variables led to an increased explained variance, however, the reduced relationship of green exercise with SRH in the controlled model indicates that Educational level and Language proficiency have a major impact on people's SRH. Differently, the explained variance for the association of Green exercise with SWL was higher , showing a substantial contribution to the overall explained variance in the controlled model, as suggested by the relatively small reduction of the association when the control variables were included. Indeed, Green exercise appears to account for almost half of the explained variance for SWL in the controlled model. These findings are partly in keeping with previous research. While some studies found significant associations of green exercise with both SRH and SWL [9,11], a German study found that participation in leisure outdoor activities was significantly and positively associated with SWL but not SRH [10]. Moreover, review studies of experimental trials found more consistent effects of green exercise on indicators of wellbeing such as self-reported psychological states, as opposed to indicators of physical health such as blood pressure or stress hormones [14,15]. The findings of the present study indicate that such patterns can be extended to immigrant populations, while at the same time showing how immigration-related factors can influence the salutogenic benefits of green exercise, even among highly skilled and resourceful immigrants from relatively similar cultural contexts, as for the case of the Italians in Norway. Moreover, the findings emphasize the complexity of the pathways linking green exercise with health and wellbeing among immigrants, which will be discussed more in depth in the paragraphs below. --- Appreciation of nature and green exercise The qualitative analysis highlights that the Italian immigrants generally noticed and appreciated the greater accessibility to nature in Norway compared to Italy. The participants reported to seek contact with nature to reduce stress, but also to enjoy pleasant leisure activities, alone or in company. Accordingly, the descriptive statistics indicate that many Italian immigrants have frequent experiences in nature, most of whom reported to engage in some green exercise during a regular week. Indeed, as described in the introduction, not only the Italian immigrants in Norway practice green exercise in a similar extent compared to the general Norwegian population [25], but they also show considerably larger participation ratings compared to the Italians living in Italy [66], which suggests that the Italian immigrants tend to increase their practice of green exercise after moving to Norway. As emphasized by our qualitative analysis, this seems to be partly facilitated by the greater availability of natural environments in Norway compared to Italy. The perceived wellbeing benefits also seem to contribute supporting the practice of green exercise among the Italian immigrants. The anticipated psychological benefits of being in contact with nature as well as having an emotional attachment to nature, both of which can be strengthened through experiences in nature [13,67,68], are important psychological factors supporting the practice of green exercise. For instance, a Norwegian national survey showed that the desire of experiencing nature was a primary motive predicting green exercise behaviour [69]. Qualitative studies from Norway and the U.K. also indicate that green exercise is often motivated by the desire of engaging with natural qualities for physical and cognitive restoration [70], which ascribe meaning and value to health and green exercise [71]. In this respect, it is important to consider the Italians' cultural understanding of nature. For instance, interviewees mentioned valuing aesthetical elements, such as the sight of a deer, which represents a typical, romantic relationship to nature [72]. This suggests that the Italian immigrants' notions and definitions of nature may not differ considerably from the hegemonic understanding among the Norwegian population [73]. --- Novelty vs. familiarity In the interviews, it is evident that, despite some recognised differences between Italian and Norwegian nature, the participants were familiar with some characteristics of the Norwegian landscape. Moreover, in keeping with the quantitative measures, many had previously engaged in green exercise, though activities such as hiking and downhill skiing. This may suggest that the familiarity with this activity facilitated the practice of green exercise among immigrants. In this respect, an interesting extension was provided, though the quantitative finings, by the negative association of Childhood experiences with SWL, which indicates that those who had less frequent experiences with green exercise during their childhood were more likely to gain greater wellbeing benefits from practicing green exercise as adults in Norway. Cross-sectional studies have previously demonstrated that childhood experiences with green exercise is a major predictor of green exercise in adulthood [13,57]. Moreover, previous studies showed that immigrants in Norway who come from countries where green exercise is little practiced, tend to prefer sedentary outdoor activities such as having a picnic or resting [74], rather than practicing 'active' forms of green exercise such as hiking in the forest or mountains [75]. Nevertheless, the present study's findings indicate that not only Italian immigrants who had little experience with exercise during childhood can learn to embrace the green exercise culture in Norway, but this practice tend to be associated with greater wellbeing among the 'novice practitioners' compared with those who were more accustomed to this activity. --- Social facilitation The multivariate logistic regression indicated that greater Social support for green exercise is a highly significant and independent predictor of higher SWL, indicating that the social context plays a key role in the pathways that link green exercise to wellbeing among Italian immigrants in Norway. From the interviews, it is evident that the social component is a heavily present element in the Italian immigrants' practice of green exercise. This is in line with previous research demonstrating that social support and other social aspects are important facilitators of green exercise [13], which contribute and strengthen the wellbeing effects associated with this activity [4]. Indeed, it has been argued that sociability and social support can be both a factor promoting and supporting the practice of green exercise, as well as a desirable outcome of this practice [1,4]. The findings are also in line with previous research involving other immigrant groups in Norway. For instance, a qualitative study found that, among immigrant women in Norway, nature experiences and green exercise often included leisure pursuits with close friends or family members [26]. However, an unexpected expansion provided by the qualitative findings suggests that Italian immigrants may, at times, negatively evaluate the social norm surrounding the practice of green exercise in Norway. --- Green exercise and acculturation Previous studies indicate that immigrants may experience barriers to green exercise due to unfamiliarity with using nature for leisure, difficulties in retrieving information on how to reach places where they can hike, swim, ski, etc., but also because of economic barriers [27,76]. Through a process of acculturation, immigrants may overcome these barriers and integrate new forms of green exercise in their lives. The multivariate logistic regression showed that Language proficiency, as a general indicator of the immigrants' acculturation, was a highly significant predictor of both SRH and SWL. This suggests that general acculturation is important for immigrants' health and wellbeing, independently or even beyond the practice of green exercise. That said, the intertwined effect of language proficiency and green exercise on SRH and SWL strengthen the idea that acculturation may take different paths in reinforcing the process of becoming part of a new society. That is, participating in green exercise, which is most relevant in the Norwegian context, may be seen both as the result of acculturation but also as a way of developing a sense of belonging to a new community and promoting the knowledge of the language and other aspects of the Norwegian society. The qualitative findings provide interesting extensions, highlighting how Italian immigrants noticed differences in their cultural practice of green exercise 'Italian style' compared to what they interpret as 'Norwegian. ' In particular, our analysis highlights that positive evaluation of green exercise may be achieved when coupled with adaptation to ones established cultural norms, such as starting to appreciate being out in the cold, but only to a certain degree, or hiking at a comfortable pace. --- Strengths and limitations This study expands current knowledge on the relationship of green exercise and human-nature interactions with the health and wellbeing of individuals, particularly in the context of intra-EEA migration. Additionally, it provides novel insights into the experiences of Italian immigrants, a group that has received limited research attention. By employing a mixed methods methodology, we were able to establish statistical evidence on the association among green exercise, relevant correlates, and the health and wellbeing of Italian immigrants. Additionally, we gained a comprehensive understanding of their perceptions and experiences through qualitative analysis. The study adhered to rigorous and transparent procedures for conducting mixed-methods research. However, the study has several limitations. Firstly, it focuses specifically on Italians living in Norway, and the findings may not be applicable to Italian migration patterns in other countries due to potential differences in socio-demographic and migration-related characteristics. It is important to note that Italian immigrants in Norway tend to have higher levels of education, potentially reflecting unique migration trends and the appeal of Norway as a destination for voluntary migrants, but which might have provided a limited overview on the phenomenon. Another limitation related to the recruitment process for the survey . It was not possible to access a complete and updated contact list of Italian residents in Norway, which restricted our ability to employ randomized or stratified sampling. The use of the Italian Embassy's newsletter, COMITES Oslo's mail-list, and groups on social media to recruit participants may have inflated the proportion of individuals that are affiliated to such groups. We mitigated this limitation by oversampling the dataset to balance key socio-demographic characteristics, thereby enhancing the representativeness of our sample. This was done through the ADASYN approach, which creates artificial examples that closely mirrored respondents' answers, minimizing distinguishability. However, it is important to acknowledge that such oversampling approaches may inadvertently amplify patterns in the data, potentially overestimating analytical results. Fortunately, the dataset employed in this study does not appear to have been affected by this issue. While some of the instruments used in this study, such as SRH and SWL, have been previously validated and widely employed in population studies, the validity of other instruments, such as those related to green exercise, childhood experiences, and social support, is less established. These variables were constructed using individual items retrieved from a previous survey conducted by a professional statistics agency . The same dataset has been utilized in a subsequent study with a similar approach [13]. To address the limitations of our approach, we provide detailed descriptions of the instruments, present descriptive statistics for individual items, and conduct preliminary analyses to assess internal consistency. However, it is essential to exercise caution regarding the limited validity of these variables. Limitations in the qualitative part of the study need also to be reported. The use of snowball sampling may have reduced variation in the sample as informants were recruited trough the researchers' network. This sampling strategy limits the generalizability of the qualitative findings, and effort to include large variation in socio-demographic characteristics and experiences of being and Italian in Norway should be made in future research. --- Conclusions The findings of the present mixed-method investigation indicate that Italian immigrants to Norway appreciate the greater opportunities for green exercise in Norway compared with Italy, and experience this as beneficial to their health and wellbeing. The study sheds light on the complex pathways that link green exercise with health and wellbeing, highlighting the specific challenges and barriers experienced by this group of immigrants in relation to the practice of green exercise. The study also emphasizes the importance of framing this phenomenon under the prism of acculturation as, in the Norwegian context, friluftsliv is a specific culturally informed practice of being healthy and can be seen as an important aspect in becoming part of a new society. Although this study focuses specifically on Italian immigrants to Norway, the findings provide valuable knowledge for understanding green exercise participation among other immigrant groups. Moreover, this study highlights that more research is needed to understand how different immigrant groups, including those from EEA countries, practice green exercise in their own acculturated ways. --- List of Abbreviations --- Data Availability The datasets supporting the conclusions of this article are available from the corresponding author on reasonable request. --- --- Funding This study received funding for administrative expenses and to arrange dissemination seminars from the Italian Ministry of Foreign Affairs through COMITES Oslo. None of the authors is employed or an elected member of COMITES Oslo or the Italian Ministry of Foreign Affairs, nor has received direct funding to conduct this research. The authors' participation in the research activity was entirely funded by their respective institutions. AR's participation was additionally funded by European Community's H2020 Program under the funding scheme INFRAIA-2019-1: Research Infrastructures grant agreement #871042 . --- --- --- Competing interests The authors has/have no competing interests to declare. ---

Background Green exercise (physical activity in presence of nature) has beneficial effects for health and wellbeing. Green exercise is a popular form of recreation in the Nordic countries, but participation is lower among the immigrant population from non-Western countries. However, no attention has been given to immigrants from the European Economic Area regarding this topic. Given the cultural and structural differences that surround green exercise in Italy and Norway, the case of the Italian immigrants in Norway is of interest to enrich our understanding of green exercise and its significance for health and wellbeing among immigrants in the Nordic countries. Methods This convergent mixed methods study investigated the pathways that link green exercise to health and wellbeing among Italian immigrants in Norway. Quantitative data were collected through an online survey (n = 321), which was oversampled to better reflect the sociodemographic profile of the reference population. Logistic regression was used to model the association of green exercise with self-rated health (SRH) or satisfaction with life (SWL) before and after controlling for selected confounders (age, gender, educational level, language proficiency, social support, and childhood experiences with green exercise). Qualitative data were collected through semistructured in-depth interviews (n = 14) and analysed thematically. Merging of the two strands was done using a simultaneous bidirectional approach.The logistic regression found a significant bivariate association of green exercise with both SRH and SWL, though the association remained significant only for SWL after controlling for confounders. From the thematic analysis, three themes were identified: Green exercise opportunities contributing to overall satisfaction, Closeness to nature, and Embracing a new lifestyle. The integrated findings indicate that green exercise supported the immigrants' wellbeing, especially by providing stress relief, though socioeconomic status and acculturation may have a major impact on general health. Familiarity, appreciation of nature benefits, social support, and acculturation were identified as facilitating factors.This study provides novel insights into how green exercise supports health, wellbeing, and inclusion among immigrants to the Nordic countries and emphasizes the importance of developing culturally adapted strategies to enhance this health-promoting activity among immigrant populations.

INTRODUCTION Bijlsma reported that AIDS is a disease caused by a retrovirus known as HIV which attacks and impairs the natural defense system of the body against disease and infection. Bijlsma further stressed that HIV is a slow-acting virus that may take years to produce illness in a person. During this period, the defense system of an HIV-infected person is impaired, and other viruses, bacteria, and parasites take advantage of this "opportunity" to further weaken the body and cause various illnesses, such as pneumonia, tuberculosis, and oral thrush. Human immunodeficiency virus is one of the worst infections that have decimated the human population, especially in resource-compromised societies such as developing African countries. In Africa alone, nearly 25 million are living with HIV/AIDS, the vast majority of the adults in the prime of their working and productive age . About 15 million people in Africa are reported to have died of AIDS, while about 12.1 million children have been orphaned in Africa because of the infection . HIV infection constitutes a global public health emergency and is most prevalent in areas of the world where undernutrition is a serious concern. Despite tremendous advances in care for HIV infection and increased funding for treatment, morbidity and mortality due to HIV/AIDS in developing countries remain unacceptably high. Globally, the HIV burden is least in the richest countries, however, in sub-Saharan Africa countries HIV prevalence is highest in the wealthiest countries. Nigeria is reported to be the second in the world with the highest number of new HIV infections reported each year and an estimated 3.7% people of the population are estimated to be living with HIV . However, the rate of infection has reduced in Nigeria, as reported by Nigeria National HIV/AIDS Indicator and Impact Survey that, the prevalence of HIV in Nigeria is 1.4%. Despite the recent reduction in the rate of infection, there is a need to scale up nutrition assessment and education is thus pertinent to slow the progression of the disease . Nutrition appears to be one of the major factors that play a critical role in the prevalence of HIV/AIDS, yet it is taken for granted . Nutrition for rich people is satisfaction in the fact that there are no food items that are beyond reach; for the poor, there is consolation in the fact that only what can be afforded is eaten and for the average majority there is solace in the fact that there is no obvious problem with what to eat . Knowledge means the ability to pursue and use information, while attitude indicates the result of making a reaction through some ways in some situations. Therefore, nutrition is a significant determinant of individual anthropometric status, which in deficiency state results in malnutrition. However, having access to food items is not enough but knowledge of nutrition and attitude toward nutrition is paramount to improve the nutrition and health status of people living with HIV/AIDS. Thus, the present study is targeted at the influence of socioeconomic status of people living with HIV/AIDS on their anthropometry, nutrition knowledge, and attitude, attending a special treatment center in National Hospital Abuja, Nigeria. --- METHODOLOGY Study Design The study was conducted at the STC, an out-patient clinic in National Hospital Abuja, Nigeria. National Hospital Abuja is a multidisciplinary tertiary hospital located in the Central district of Federal Capital Territory, Abuja. A cross-sectional study design was used to assess the influence of socioeconomic status on anthropometry, nutrition knowledge, and attitude of people living with HIV/AIDS attending STC Abuja, Nigeria. The population of the study was people living with HIV/AIDS attending STC in National Hospital Abuja, who are aged 18-64 years old. --- Choice of Respondents The respondents were out-patient HIV-affected individuals, and this was because the study has no required capacity to assess inpatient HIV-affected individuals. The study also considered those that have been HIV-positive for 2 years and above, in order to have a clear understanding of how socioeconomic status could influence their attitude toward nutrition and its knowledge and anthropometry, so as to draw a better inference in the study. --- Sample Size Determination and Sampling Procedure The sample size was calculated using the formula for a known population by Yamane : n = N/1 + N 2 n = sample size N = population size e = level of precision required for the results N = 5,405; e = 0.05. 5,405 1 + 5,405 2 = 360 : Thus, 10% dropout was; 36 + 360 = 396. Therefore, the sample size for the study was three hundred and ninety-six . Sampling procedure: Proportion allocation was used to select the number of men and women that were included in the study. Thus, the formula: n i = N i /N × n Rajiv . N = total population, N i = total number of male/female living with HIV/AIDS, n i = number of male/female in the ith group. N = 5,405; n = 396, N i = 2,800 /2,605 . However, using the formula above; For the male; n i = 2,800/5,405 × 396 = 205. For the female; n i = 2,605/5,405 × 396 = 191. The study population attends STC once in 2 months, and there ∼4 weeks in a month. They were grouped since the center runs Monday to Thursday weekly. For the first 4 weeks, there were 16 groups and by 2 months, the groups were altogether 32 groups. The number of PLWHA [males and females ] were spread across the 32 groups, giving 6 male participants and 6 female participants . The sample size was the basis for the study, however, the total number of the PLWHA and female subjects) that were used for the study was two hundred and seventy , which was about 68.2% response rate. Thus, in each group, there was a total of 12 subjects both male and female, but this was reduced to nine subjects per group due to the response rate. In each of the groups, the subjects were segregated by sex, and then, simple random sampling by balloting without replacement was used to select the number of subjects required for the study on each day of visit. Everybody was given an equal opportunity to be picked and those that picked "Yes" were used for the study. Ethical approval was obtained from the Ethical Committee National Hospital Abuja, allowing the researcher to use their subjects for the study. Trained clinical nutritionists, registered dietitians, nurses, and laboratory scientists were used in the study to evaluate the out-patient HIV-affected individuals, through one-onone interviews. Before administration of the questionnaires, written and/or oral informed consent was obtained from each patient after being assured of the confidentiality of volunteered information. Nutrition education including dietary counseling was the major incentive given to the participants after the data collection. --- Data Collection The structured and validated questionnaire was used to collect information on the background information and socioeconomic characteristics of PLWHA, their nutrition knowledge, and their attitude toward nutrition. The questionnaire was administered to the respondents during their scheduled appointments in the STC National Hospital, Abuja. --- Anthropometric Measurement Weighing scales and meter rules were used to obtain weights and heights of subjects, respectively, using standard procedure: subjects were weighed three times with minimal clothing and the average of the reading was recorded to the nearest 0.1 kg. The height was measured with subjects standing against a wall, their heel, buttocks, and vortex against the wall for their heights to be measured in centimeters. An average of two readings was recorded to the nearest 0.1 cm. Their body mass index was calculated using and recorded. World Health Organization classification of BMI was used to classify the subjects into underweight, overweight, and obese. Skinfold thickness was also measured and calculated to the nearest 0.1 cm using a skinfold caliper. --- Determination of Knowledge and Attitudinal Questions Knowledge was assessed by the use of knowledge questions where a grading method was used to develop a nutritional knowledge index. A list of 15 nutrition-related questions was presented to the respondents and responses were marked and scored. For every correct response, 1 mark was given while for each wrong response a score of 0 was given. A respondent can score a maximum of 15 and a minimum of 0 in the knowledge section. The attitude was assessed using a three-point scale . This method was used for grading the intensity of attitudes of the respondent toward adequate nutrition. The Likert scale comprised of one positive, a middle option that captures attitudes that are still uncertain and one negative, a score of 1 was given to "disagree, " a score of 2 was given to "do not know, " and a score of 3 was given to "agree, " so that a respondent could score a maximum of 45 and a minimum of 15 in the attitude section. --- Data Analysis Data were collected on the socioeconomic characteristics of the respondents, their nutrition knowledge, and attitude toward nutrition using a structured questionnaire, and analyzed. Nutritional status using anthropometric measurements were measured and analyzed. The BMI was calculated and compared to WHO BMI standard, underweight , normal , overweight , and obese , and nutrition knowledge score was graded thus, Poor , Fair , Good , and Excellent while attitude was assigned thus, Disagree , Undecided , and Positive . --- Statistical Analysis Descriptive statistics were used to analyze the categorical and continuous variables such as socioeconomic characteristics, knowledge, and attitude grades of the respondents. Chi-square was used to analyze the anthropometric status, while regression analysis was used to determine the influence of socioeconomic predictors on anthropometric status, nutrition knowledge, and attitude of PLWHA. --- RESULTS AND DISCUSSION Table 1 shows the background information and socioeconomic characteristics of the respondents. Few male and female respondents were aged 34-41 years of old. The higher percentage of this age range living with HIV was because at this age young people experiment with sex and take risks. It is therefore not surprising that the higher number of the respondents belonged to this age group. The higher number of the respondents who belonged to this age range concurred with previous studies inside and outside of Nigeria . Most of the male respondents were married while more than half of their female counterparts were also married. This suggests that men were more infected than women by HIV. This finding does not support the report by UNAIDS who reported that more women were living with HIV/AIDS in sub-Saharan African than HIV/AIDS positive men. This study concurred with the study done in Nigeria . The educational status of the respondents revealed that some of both male and female respondents, respectively, had tertiary education while few and respectively of both male and female respondents had secondary education. Therefore, amongst all the respondents, few and some had secondary and tertiary education respectively, while few of them had no formal education. This finding is similar to previous studies from Ezechi and Aliyu et al. who stated that the high educational attainment of the respondents could be attributed to the location of the study area. Some of the male and few of the female respondents were civil servants, while few of the male and some of the female respondents were traders. The highest average monthly income amongst the male respondents was N ==41,000 and above while amongst the female respondents some earned <N ==10,000 monthly. The result also revealed that amongst the total respondents, a few of them earned <N ==10,000 monthly. Although the majority of the respondents were engaged in incomegenerating activity, their incomes of N ==10, 000 per month, or less indicated that the respondents were employed in low-paying jobs. This finding is in agreement with the study done by Sakhile et al. , where the majority of the respondents earned less income because they were engaged in low-paying jobs. Table 2a reveals the nutrition knowledge status of the respondents, thus, less than half of the respondents had poor knowledge of nutrition, while 29.1% had both fair and good knowledge of nutrition, however, very few had excellent knowledge of nutrition. The respondents' mean nutrition knowledge score was 38.63 ± 17.53. The study revealed that more respondents had poor knowledge on adequate nutrition and this could be due to insufficient nutrition education during their visit to the hospital and/or due to being absentminded and probably depressed as a result of their present condition. However, the importance of adequate nutrition for PLWHA cannot be overlooked. Akumiah et al. reported that nutrition knowledge score was greater in those that received sufficient education on nutrition compared to those who did not receive sufficient nutrition education. Furthermore, poor nutrition knowledge plays a key role in the rapid progression of HIV, and this is in line with the study by Muthamia et al. who reported that adequate nutrition knowledge is also among key factors that determine the quality of life among PLWHA, although they have been largely overlooked, especially in resource-limited settings. Table 2b shows the attitude of respondents toward nutrition. A little more than half of the respondents had a positive attitude toward nutrition while 47.2% of them were undecided about their attitude toward nutrition. The mean attitudinal score of the respondents on nutrition was 2.36 ± 0.36. The study showed that more of the respondents had a positive attitude toward nutrition. This validates the choice of respondents concerning the duration of the disease, which supports the view that prolonged exposure to HIV influences the endocrine secretion levels which in turn could influence their attitudes toward adequate nutrition, and thus, may indirectly affect their nutritional status. Furthermore, it could also be due to the fact that eating a variety of food in moderation is key to adequate nutrition and also the respondents had a good attitude that maintaining a healthy diet is their responsibility and that skipping meals is not good for their health. This is in agreement with the studies done by Bukusuba et al. and Deyika and Thahira that a good number of PLWHA understood that consumption of a balanced diet, fruits, and vegetables is necessary for good health, and skipping meals would increase the side effect of antiretroviral treatment. This, therefore, suggests that nutrition knowledge alone could not be sufficient enough to change dietary habits and/or practices, however, a positive attitude toward nutrition is important to healthy eating and more so, accessibility to nutrition sources. Table 3 reveals the anthropometric status of the respondents. Thus, 49.3% of the respondents had normal weight, of which 57.4% were male and 39.2% were female. The female respondents were found to be overweight more than their male counterparts; 25.0% of men and 32.5% of women had BMI equals 25.0-29.9 kg/m 2 . More so, 20.0% of female respondents were obese while 7.4% of their male counterparts were obese. There was a significant difference in the BMI status between male and female respondents, thus it was discovered that men had lower fat than their female counterparts. This is in line with studies by Walsh et al. and Gideon and Olamide that reported essentially lower fat in men with about 3.0% of the total weight vs. 12.0% in women. It has been reported that the higher fat percentage in women is due to sex-specific fat, such as breast, uterus, and other sex-related fat deposits . The result also showed the skinfold status of the respondents where 56% of the respondents were malnourished; more than sixty-four percent of the men were malnourished than their female counterparts while 54.2% of the female had normal skinfold compared to 35.8% of the men. The chi-square showed that there was a significant difference among the male and female respondents concerning their skinfold status. Using triceps skinfold status, the male respondents were malnourished compared to the women and the percent body fat was significantly higher and/or normal in women than in men. This could be due to the fact that females tend to lay down more subcutaneous fat layers than males during the growth spurt at puberty. The finding of this study is in line with the study by Gideon and Olamide . However, malnutrition is a serious danger for PLWHA, even at the early stages of HIV infection when no symptoms are apparent, HIV makes demands on the nutritional status of the body . Table 4 shows the influence of background information and socioeconomic status on the BMI, skinfold, nutrition knowledge, and attitude of the PLWHA. The BMI of the respondents was significantly positively influenced by gender but negatively influenced by age . These variables contributed 7.6% in the variability of the BMI of the respondents. Female respondents were observed to have BMI values 2.63 kg/m 2 higher than their male counterparts while young respondents had BMI values 1.89 kg/m 2 lower than respondents 34 years and above. Gender was the only socioeconomic characteristic that had a significant and positive influence on the skinfold thickness of the respondents. The study showed that being female contributed 0.87% to the variability in the skinfold thickness and women had skinfold thickness 5.23 cm higher than the men. Gender and age had an influence on the BMI while being female alone influenced the skinfold thickness of the respondents. This could suggest that women are more likely to adhere to treatment regimens and have access to health services than men, and this may have contributed to having a better BMI and skinfold thickness than their male counterparts. Thus, an increase in BMI and skinfold thickness are indications of improvement in physical health which helps to increase self-confidence. However, the study is in contrast with the study by Yen et al. where male patients had a better BMI and skinfold thickness than their female counterparts. They further suggested that better BMI and skinfold thickness contributed to the quality of life of PLWHA, increase self-confidence, infuse a sense of independence wherein they move around and feel accepted in the environment they stay in. The result also suggested that young age influenced the BMI of PLWHA. This could be due to the fact that young adults may be particularly susceptible to inadequate dietary intake due to the stigma associated with HIV/AIDS. This may also lead to undernutrition and thus, could have contributed to the low BMI reported in this study compared to those aged 34 years and above. This is in agreement with a study by Lori et al. that young PLWHA is invariably exposed to many of the same risks for higher BMI that are relevant to the general population, however, due to the stigma associated with HIV/AIDS, they tend to live discriminately. Table 5 reveals that type of occupation and gender were the strongest and positive predictors of nutrition knowledge of the respondents. The study revealed that being Female respondents also had a 6.28% score in nutrition knowledge more than male respondents. From the study, the type of occupation and gender influenced the nutrition knowledge of the respondents. This could be attributed to their level of exposure and/or quest to living healthy and as such, they may be open to knowledge on nutrition such as dietary diversity and also nutrient-dense foods, as it concerns the management of HIV/AIDS thereby reducing the risk of opportunistic diseases. The study is in line with the study by Muthamia et al. thus, nutrition knowledge influences the choice of nutrient-dense foods that are high in nutrients compared to their weight. The attitude of the respondents was significantly predicted by gender, educational status, and marital status, which contributed 7.4% to the variability of the attitudinal score. The study showed that low educational status and being single negatively influenced the attitude of the respondents toward nutrition. Respondents with low educational status had an attitudinal score of 0.15 points lower than those with high educational status while respondents who are single or not living with their spouse were 0.12 points lower in their attitude compared to those that are living with their spouse. However, female respondents had a higher attitudinal score than the male respondents. Low educational status and being single had a negative influence on the attitude of the respondents toward nutrition. This may be due to lack of interest which could influence their attitude toward nutrition and/or with low educational status, they may have low-paying jobs with lowincome generation and as such may feel less concern toward nutrition with the belief that a good and nutritious diet is expensive. The finding is in agreement to some extent with a study by Liu et al. that most patients with HIV have no education, focus on only the drugs they have been given, and that they have a poor attitude toward nutrition in fulfilling the nutritional needs of the antiretroviral therapy in helping them to live longer with a better quality of life. More so, low and/or no education can predispose PLWHA to inadequate dietary intake which invariably increases the risk of opportunistic diseases, and thus, their immune system is compromised. --- CONCLUSION From this study, it can be seen that background information and socioeconomic characteristics such as education and occupation have a significant influence on the anthropometry of people living with HIV/AIDS. Thus, nutrition knowledge and attitude is not a standalone tool, however, proper education, occupation , and of course, high income are important variables, which when in place and sustained, will promote the anthropometric and health status of people living with HIV/AIDS thereby leading to a healthy nation at large. --- DATA AVAILABILITY STATEMENT The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s. --- ETHICS STATEMENT The studies involving human participants were reviewed and approved by Ethical Committee National Hospital Abuja Nigeria. The patients/participants provided their written informed consent to participate in this study. --- --- Conflict of Interest: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Publisher's 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.

The work is on the influence of socioeconomic status of people living with HIV/AIDS (PLWHA) on their anthropometry, nutrition knowledge, and attitude, attending special treatment center (STC) in National Hospital Abuja, Nigeria. A cross-sectional study design was carried out in the STC and a total of two hundred and seventy [270 (150 men and 120 women)] PLWHA were used for the study. The PLWHA attend STC once in 2 months and subjects were grouped into 16 giving 4 groups per week since the center runs Monday through Thursday weekly and by 2 months, there were altogether 32 groups. Socioeconomic characteristics, nutrition knowledge and attitude, and anthropometric data were collected. Data were analyzed using descriptive statistics, chi-square, and regression analysis. The study revealed that 41.1% of PLWHA had poor knowledge of nutrition, 29.1% had both fair and good knowledge while 0.7% had excellent knowledge. A total of 52.8% had a positive attitude toward nutrition. The skinfold status of the respondents showed that 56.0% were malnourished, while their body mass index (BMI) revealed that 49.3% were normal. Gender (being female) and age (being young) had a significant (P < 0.01) influence on the BMI of PLWHA, while being female significantly influenced their skinfold status. Self-employed and being female were strongest (P < 0.01) positive predictors of nutrition knowledge, while low education had a negative influence on their attitude toward nutrition. Good nutrition knowledge, attitude, and improved socioeconomic characteristics are important tools in the care process of PLWHA, for sustainable healthy PLWHA, leading to a healthy society at large.

The vaccine misinformation landscape Rumors and conspiracy theories around COVID-19 vaccines have undoubtedly been damaging. Research conducted by the Vaccine Confidence Project in 2020 aimed to quantify how exposure to online misinformation around COVID-19 vaccines might be affecting vaccination intent 3 . As part of a randomized control trial conducted in the United Kingdom and United States, participants were exposed to examples of misinformation circulating on Twitter, including one post falsely claiming that a COVID-19 vaccine would alter DNA in humans and another falsely claiming that a COVID-19 vaccine would cause 97% of recipients to become infertile. The study found that, relative to factual information, these items of misinformation induced a decline in intent to vaccinate. In the United Kingdom, there was a 6.2 percentage point drop in the respondents who 'strongly agree' that they would get vaccinated, alongside a 6.4 percentage point drop in the same response among US respondents. Other studies have reached similar conclusions about the effect of exposure to online vaccine misinformation 4 . Until shortly before the pandemic, most social media platforms had few if any policies to address vaccine misinformation. In early 2019, in response to a series of measles outbreaks in the United States, Facebook announced for the first time that it would reduce the ranking of groups and pages promoting vaccine misinformation in its news feed and search tool 5 . It further pledged to reject advertisements that included misinformation about vaccines and to stop showing or recommending such content on the Explore and hashtag pages on Instagram, which Facebook owns. Around the same time, YouTube began to prevent anti-vaccination channels from raising money through advertisements 6 . However, these measures typically stopped short of removing misleading content. In July 2020, an investigation by the Center for Countering Digital Hate, a UK-based campaign group, found that avowedly anti-vaccination accounts on English-language social media had a combined 58 million followers, which it estimated could be worth up to US$1 billion a year to the platforms 7 . Since the pandemic began, social media companies have come under increasing public and political pressure to prevent misinformation spreading on their platforms. Facebook, Instagram, Twitter and YouTube all now have explicit policies regarding COVID-19 and vaccine misinformation more broadly. Typically, these involve a combination of signposting users to credible information sources, placing warning labels on potentially misleading information and removing content that has the highest risk of causing real-world harm. Facebook, the world's largest social media platform, claimed that by August 2021 it had removed over 3,000 accounts, pages and groups since the beginning of the pandemic for repeatedly violating its rules against spreading COVID-19 and vaccine misinformation, along with 20 million individual pieces of content 8 . Recent interventions demanded of social media companies raise major questions around whether private technological monopolies have both the democratic legitimacy and the institutional competence to arbitrate the scientific merits and likely real-world consequences of speech acts within the digital public sphere. More to our point, the shared focus on technological solutions by both platforms and critics urging them to go further in removing misinformation implies that vaccine hesitancy is still widely seen as primarily an informational problem, rather than a trust problem. This diagnosis already implies a cure: reduce the supply of false information and increase the supply of accurate information. However, increasing the supply of accurate information will not, on its own, 'cure' this problem if the underlying drivers of hesitancy remain unaddressed. --- The role of social uncertainty Rumors and conspiracy theories about COVID-19 and vaccines should not be understood simply as false beliefs. Instead, they can --- An epidemic of uncertainty: rumors, conspiracy theories and vaccine hesitancy Ed Pertwee 1 ✉ , Clarissa Simas 1 and Heidi J. Larson 1,2 The COVID-19 'infodemic' continues to undermine trust in vaccination efforts aiming to bring an end to the pandemic. However, the challenge of vaccine hesitancy is not only a problem of the information ecosystem and it often has little to do with the vaccines themselves. In this Perspective, we argue that the epidemiological and social crises brought about by COVID-19 have magnified widely held social anxieties and trust issues that, in the unique circumstances of this global pandemic, have exacerbated skepticism toward vaccines. We argue that trust is key to overcoming vaccine hesitancy, especially in a context of widespread social uncertainty brought about by the pandemic, where public sentiment can be volatile. Finally, we draw out some implications of our argument for strategies to build vaccine confidence. be read as expressions of popular fears and anxieties. These narratives typically emerge in times of acute social uncertainty. In the historical literature, modern conspiracy culture is generally traced back to the immediate aftermath of the French Revolution, which was attributed by some contemporary observers to the machinations of secret societies such as the Freemasons or the Bavarian Illuminati 9 . Conspiracy theories similarly flourished after the Russian Revolution, when the idea of an international Judeo-Bolshevik conspiracy became popular in Europe and North America, and in the United States during the early part of the Cold War, when the rising threat of Soviet communism led to the second Red Scare. Conspiracy theories represent attempts to impose narrative coherence on frightening situations such as revolutions, wars, financial crises, natural disasters or pandemics. Their ubiquity in late-twentieth and early-twenty-first century politics and culture has been linked to popular anxieties around globalization, new technologies, socioeconomic inequality, terrorism and increased surveillance, among other things 9 . They are often brought to the fore by historic events such as the terrorist attacks of 11 September 2001, the financial crisis of 2008, and the current COVID-19 pandemic. Notably, social psychologists Jan-Willem van Prooijen and Karen Douglas have argued that while conspiracy theories may emerge through the desire to make sense of one's social environment in a context of uncertainty, their distillation of "complex events into a simplified story… makes such theories ideally suited for cultural transmission as they are easily understood by lay people" 10 . Although many of the anxieties fueling COVID-19 rumors and conspiracy theories long predate the pandemic, they have probably been exacerbated by the widespread social uncertainty of the past 2 years. For instance, health scares around new technologies, from high-voltage power lines and microwaves to mobile phones, are nothing new. Moreover, conspiracy theories about 5G mobile technology specifically -for example, that it was responsible for the unexplained deaths of birds and trees -were already circulating in the years leading up to the pandemic. It is perhaps unsurprising that in the unique circumstances of early 2020 these anxieties began to be linked to COVID-19 after a Belgian physician drew a connection between the construction of 5G mobile towers in Wuhan and the novel coronavirus outbreak 11 . The myth spread first among fringe communities on social media, before being picked up and amplified by celebrity influencers and media outlets 12 . It is estimated that in a 4-day period in early April 2020, at least 20 mobile phone masts were vandalized in the United Kingdom alone by people convinced that 5G was responsible for spreading COVID-19 . Similarly, that one-fifth of Americans believe that COVID-19 vaccines are being used by the government to microchip the public shows how widespread concerns about digital surveillance and the commodification of personal data have become 14 . Again, these concerns long pre-date the pandemic and have been fueled by high-profile news stories such as the 2018 Facebook-Cambridge Analytica data-collecting scandal; however, they came to the fore during the first half of 2020 as many governments sought to harness technologies developed by the private sector, especially mobile phone data, to tackle the spread of COVID-19. Concerns about the growing and often unscrutinized role of biosurveillance as a means of controlling the pandemic are by no means confined to the political fringe. But for some who felt their lives were increasingly being controlled by the state or by remote elites, Bill Gates came to serve as the perfect scapegoat owing to his combined roles as technological innovator, capitalist entrepreneur and pro-vaccine philanthropist. --- The importance of trust A dysfunctional information ecosystem may have accelerated the spread of COVID-19 myths and conspiracy theories but, as the thumbnail history of conspiracy thinking sketched above suggests, it did not directly cause them. Rumors around vaccine safety were being communicated via traditional media long before digital technologies were available to amplify them; for instance, in the scare around the diphtheria, pertussis and tetanus vaccine during the late 1970s and early 1980s, which was fueled by mainstream newspaper and television coverage 15 . Moreover, although the information ecosystem is undoubtedly an important influence on vaccine decision-making, as our recent research on the impact of misinformation exposure demonstrates, focusing only on the information ecosystem can obscure the wider sociocultural, historic, institutional and political context. In many countries, a lack of trust in key institutions involved in the production, supply and distribution of vaccines is a crucial part of that context. Several studies have found evidence of a link between vaccine hesitancy and 'populist' distrust of political elites and medical experts. For example, a 2019 study of European Union member states found a marked positive association between electoral support for populist parties and low confidence in vaccine importance and effectiveness 16 . A similar study in the United States in 2018 found that vaccine attitudes, trust in public health experts and political worldview were all interlinked 17 . Other studies have found that measures of trust in politicians closely predict conspiracy belief 18,19 . Trust can be conceptualized as "a relationship that exists between individuals, as well as between individuals and a system, in which one party accepts a vulnerable position, assuming the best interests and competence of the other, in exchange for a reduction in decision complexity" 20 . Trust becomes important whenever there is "an implicit imbalance of power due to a high level of information asymmetry, where trusting individuals accept a vulnerable position in relation to a trusted party" 20 . It is especially important in a context of social uncertainty, such as during a public health crisis, when individuals often have to make crucial decisions on the basis of incomplete information. In relation to vaccine acceptance, multiple dimensions of trust are important. There needs to be trust in the product , in the provider and in the policy-maker . The COVID-19 pandemic and associated infodemic have magnified the underlying problem of trust. The ebb and flow of pandemic waves, together with policy uncertainty and information overabundance have all increased the complexity of decision-making. Rumors and conspiracy theories can contribute to this epistemic uncertainty regardless of whether people believe them or not. As research shows, even if individuals distrust anti-vaccination content, exposure to these narratives can still sow doubt about the safety and efficacy of vaccines or about the motives of those involved in their manufacture and administration 21 . Trust is often linked to past experiences, which is one reason why marginalized groups, such as religious and ethnic minorities, have been found to be less trusting of vaccines in general and less likely to vaccinate 22 . For example, vaccine hesitancy among Black communities today reflects historical distrust of public authorities and healthcare providers, among other factors 23 . This distrust is related to a long history of structural racism and medical abuses against Black populations, often compounded by negative personal experiences with healthcare systems and providers. Genuine concerns such as these are often susceptible to exploitation, for instance in the United States where figures connected with the Black Nationalist Nation of Islam have actively been promoting vaccine misinformation to African American audiences through a network of social media accounts 7 . While much has been said about vaccine hesitancy among minority groups, the institutional failures that have led to these attitudes often receive less attention. For example, conspiracy theories about COVID-19 vaccines have found fertile ground in Nigeria, partly due to collective memories of a controversial 1996 drug trial conducted during a meningitis outbreak, in which 11 children died and many more developed life-changing disabilities 24 . Pfizer, the company responsible for the trial, insisted that it obtained approval from the authorities and verbal consent from participants before the study, and claimed that the symptoms and deaths were due to meningitis, not the drug itself. Following legal action by the Nigerian authorities, Pfizer reached an out-of-court settlement in 2009, without admitting liability. However, a widespread perception that the company had behaved unethically likely contributed to susceptibility to believing the vaccine rumors that led to a 2003 boycott of a polio vaccination campaign in three northern Nigerian states 25 . Given the historical context, it is perhaps unsurprising that 55% of Nigerians believe it is 'definitely' or 'probably' true that harmful side effects from vaccines are deliberately being concealed from the public, according to a YouGov poll conducted in mid-2020 . --- The volatility of sentiment In a context of widespread social uncertainty, sentiment can often be volatile 27 . While the broad picture is that vaccine willingness has been on the increase since late 2020, around the time Pfizer announced it had a highly effective COVID-19 vaccine, the global trend masks considerable geographical and temporal variation. In some countries, sentiments fell sharply in spring 2021 in the context of safety concerns around the AstraZeneca vaccine 28 . An extreme example is Thailand, where YouGov polling found that COVID-19 vaccine willingness declined from 83% at the start of 2021, to 60% in mid-March when a number of countries temporarily suspended use of the AstraZeneca vaccine, before climbing to 95% by the end of that year 29 . 'Emotional epidemiology' , a term coined by Danielle Ofri in the context of the 2009 H1N1 pandemic, describes these sharp fluctuations of sentiment that often attend the discovery of new illnesses 30 . The term encapsulates how health decisions are not only determined through rational thinking, but are equally impacted by a variety of feelings 31 . Fears and anxieties related to COVID-19 are known to have impacted the pandemic response on a global scale, fueling vaccine hesitancy in different parts of the world 32 . Similarly during the outbreaks of Ebola in West Africa, fears and anxieties had negative effects on preventive behaviors such as isolation and also increased stigmatization of those who were sick 33 . Conversely, positive emotions, such as hope for a return to normality, may motivate people to comply with public health measures 34,35 . Altruism can drive individuals to participate in risky clinical trials, with highly uncertain outcomes, to help their communities 36 . Like misinformation, emotions are entangled with broader political and societal issues. Emotions can also be experienced collectively, driving larger group trust levels and action. These large-scale affective processes cannot be fully grasped in individual analyses 35 . Past collective experiences can drive groups to internalize shared emotions that might influence acceptance or rejection of health interventions or guidelines 37 . Given the scale at which COVID-19 is affecting the world, and the extent to which digital media have accelerated both informational and emotional flows since Ofri was writing in 2009, the emotional drivers of trust and confidence in different health interventions are becoming an increasingly important area of research 36 . --- Building vaccine confidence Recognizing vaccine hesitancy as being primarily a trust issue rather than an informational problem, and one that has emotional as well as rational determinants, has several implications for health policy and communication. In the first place, politicians and medical experts need to be mindful of the distinction between vaccine hesitancy and being anti-vaccine 27 . Especially in a context of uncertainty, when sentiments are volatile, vaccine hesitancy is better conceived of as a decision-making process rather than a fixed set of beliefs, attitudes and behaviors 38 . Moreover, being indecisive in a situation of uncertainty is not the same thing as being 'anti-vaccination' 27 . As described above, hesitancy can have various causes, ranging from historic community experiences to safety concerns around COVID-19 vaccines. Hesitant individuals are often consumers of anti-vaccination content, but this does not mean that they are ideologically opposed to vaccination. Communication about vaccines should start from a position of empathy and aim to rebuild trust. This requires working through trusted messengers and established relationships. For instance, training community health workers from the local communities was an important part of the Ebola response. Such initiatives are arguably even more important in the context of the COVID-19 pandemic when national political leadership has often been found wanting. One recent and particularly bold initiative is the New Zealand government's collaboration with gang leaders to promote COVID-19 vaccines to hard-to-reach communities, in an effort to overcome ethnic disparities in uptake 39 . Conversely, politicians and public health authorities should carefully weigh the risks when considering measures that could potentially be perceived as coercive or stigmatizing by hesitant communities and individuals. For example, recent research by the Vaccine Confidence Project on public attitudes toward COVID-19 vaccine passports in the United Kingdom found that, although in overall terms vaccine passports had a positive effect on vaccine intent, the effect was polarizing. Passports made those who already intended to get vaccinated even more positive toward it, but had the opposite effect on those who had concerns about the vaccine 40 . Notably, it was among groups with lower uptake, including Black communities, that the effects of domestic vaccine passports were most negative. This is likely linked to longstanding suspicions of medical interventions, derived from historical experience, as described above. Although the emphasis should be on building trust, measures to tackle misinformation still have an important part to play. There has been a recent and welcome shift in emphasis from reactive measures such as content removal and fact-checking by social media companies, to more proactive ones that seek to build resilience against potentially harmful ideas before people are exposed to them. This is backed up by research showing that it is possible to confer psychological resistance to misinformation through a combination of forewarning and pre-emptive refutation 41 . Approaches can range from individual-level interventions to build resilience against misinformation, such as the 'Bad News' game to societal-level initiatives to promote health and media literacy through school curricula as is being conducted successfully in Finland 42,43 . --- Conclusion It is important to recognize that some of the factors fueling vaccine hesitancy, such as anxieties around the pace of technological change or feelings of political disempowerment, are not within the control of the medical community. As the example of health and media literacy initiatives in schools suggests, addressing such issues will require a long-term effort on the part of multiple stakeholders working across several sectors of society 43 . Like the virus that gave rise to them, it seems probable that myths and conspiracy theories around COVID-19 and vaccines will be things that we all need to learn to live with and manage for some time to come. In this new landscape, the best measure of progress toward building vaccine confidence for the longer term is perhaps not the number of doses administered so far, but public trust in the institutions responsible for delivering them. --- Competing interests

t has now been 2 years since the World Health Organization (WHO) declared that, alongside the COVID-19 pandemic, it was also fighting an 'infodemic' -an "overabundance of information, both online and offline" 1 . One index of the scale of this infodemic was that during April 2020, Twitter reported seeing a COVID-19related tweet every 45 milliseconds 2 . The huge cascade of viral misinformation that has formed part of the COVID-19 infodemic has included conspiracy theories about the origins of the virus as well as suspicions around the motives behind government COVID-19 control measures. In this Perspective, we discuss the new digital communications landscape in relation to vaccines, emphasizing the role of trust in overcoming hesitancy and building vaccine confidence beyond the current pandemic.

Introduction This paper examines the effects of ageism on older college faculty in U.S. higher education. Ageism is one of the most socially-accepted types of prejudice; it is a way of stereotyping and discriminating individuals exclusively based on their age group . It also includes age-typingthe view that some occupations are more suitable for either older or younger workers. Colleges are undergoing aging in their work environments and are subject to similar prejudices found in other fields. The number of professors 50 and beyond has declined since the 1990s , and depending on certain college policies, older age has prevented them from accumulating the benefits that come with years of experience. Social closure theory is the theoretical framework used in this analysis. By and large, the theory rests on the premise that people in their own groups seek to make the most of benefits by limiting access and freedoms to out-group members. This usually happens through organizational omission and main group convergence. In-groups are often distinguished through closeknit connections or similarities among members. The objective of social closure is to maintain a status hierarchy and the multiple advantages that come with it . IJSSES Discussion about diversity in U.S. higher education is mostly focused on students, thereby discounting the necessity to improve diversity among its workforce . Specifically, less attention has been given to the diversification of older faculty members or their experiences with ageism. Even though the topic of ageism is diverse in and of itself, more research needs to be done on sociodemographic factors and how they relate with workplace discrimination among older workers. This is what makes this analysis significant. It examines how older college faculty of different backgrounds have been denied opportunities based on their age. An important conclusion of this analysis is that, although science has been viewed as a domain for the young, little evidence exists about the correlation between age and productivity among faculty in U.S. higher education. Therefore, engaging in social closure is not necessary at U.S. colleges and universities. This paper begins with a description of social closure theory and its role in the workplace. Then, the authors proceed to address the essence of ageism and its effects on workers or job applicants. What comes subsequently is the heart of this analysis: the examination of ageism among older college faculty in U.S. higher educationalong with a consideration of other diverse groups . This paper ends with a discussion that also offers suggestions for future research. --- Review of Social Closure Theory Social closure theory postulates that in-groups devalue and control the benefits of out-groups by shutting down opportunities . In-groups are often distinguished through close-knit connections or similarities among members . This definition suggests that groups of people keenly try to invest in holding titles of power for their own key members . Put another way, exclusion comes from marginal practices within individual and organizational occupations . Some argue that these practices appear pre-planned and generate benefits only for dominant group members . Therefore, social closure happens when chances for advancement are sealed from outsiders and kept only for members of one's particular group . It deals with defending opportunities for the majority while denying them to minorities . This problem has been noted with the glass ceiling effect, whereby certain minority groups like women have a more difficult time advancing in particular fields . Sometimes, all it takes is a collective ethnicity, nationality, race, or gender to create a central group affiliation. This creates a type of social closure, like other types of discriminatory practices. It becomes strictly reinforced as those at the top exclude others from taking the advantages and resources they accumulate . In fact, status groups sustain their identity and rewards by keeping certain opportunities for group members only . To put the theory in perspective, it is imperative to know how it functions in the workplace. First, it would be interesting to look at the similarities that social closure theory has with social identity theory . --- Similarities with Social Identity Theory Social closure theory is akin to Tajfel's social identity theory . SIT posits that in-groups create separations from out-groups. In-groups and out-groups do not necessarily disagree on various attributes or identity cues. Yet, in-group members share feelings of common destiny with other members of their ingroup. The corollary could be stigmatization of out-group members, leading to an "in-group vs. out-group" distinction. Naturally, this can result in rejection of the Other . Boundaries enable insiders to decide whether certain people may be included or not. In a similar fashion, in-group members are able to reinforce group solidarity by excluding outsiders who unsettle established standards of behavior within the group . --- Social Closure Theory in the Workplace Due to burdens imposed by changing organizational structures, requests for entering executive-level jobs have increased for minorities. However, inflexible organizations like colleges and other government establishments usually remain stationary . Social closure methods are typically encountered when those of higher status categorize different groups or non-members into work that is unfavorable . Organizations that are tradition-oriented are more prone to replicating and supporting past behaviorsas opposed to reacting to what their employees actually need . This is where social restrictions and separation are not evidently defined since majority groups often play a small/absent part in forming longterm change . Therefore, social closure leads us near a route where stratification ladders are both clear and sustained. It lends to examining the activity of key performers and how workplace discrimination can occur as they become exposed. Businesses can then expect to see grouplevel achievement and workplace discrimination after considering their organizational weaknesses . The connection between job planning and social closure is well noted in research . Tomaskavic-Devey and Stainback believe that, under social closure, desirable jobs are expected to assimilate more gradually. If they ever do, leading groups will try to maintain control over these occupations, regardless of whether they fail managing all responsibilities. On the other hand, different groups of people reach top-level ranks and oversee other groups of people in what is known as bottom-up ascription. These ranks shift as social closure burdens become more fragile, mainly when leading groups have less reason to dismiss people . Hence, this theory can shed light on workplace discrimination in U.S. higher education, particularly because it encourages organizational possession of the issue. While ethnicity, gender, and race do impose issues on U.S. college campuses, age discrimination towards older college faculty has been underexplored. Before getting into details, it is important to know what counts as ageism and what effects it has in the workplace general. --- Ageism in the Workplace Ageism is one of the most socially-accepted types of prejudice. By definition, ageism is the method of stereotyping and discriminating against individuals exclusively based on their age group . Synonyms for ageism are age discrimination, age-based discrimination, age-typing, and age bias . Along with it comes age-typingthe view that some occupations are more suitable for either older or younger workers . This can lead to the mistreatment of older workers, who might then leave businesses with filed lawsuits. For illustration, when older workers try to find a job fit for a young person, lab studies reveal they are more likely to get lower evaluations and expect to execute tasks below par . The number of occupations available for young-sector jobs is exceeding past older-type positions. Additionally, the number of workers over 55 years old is increasing 36 times faster than all other age groups . In 1967, the Age Discrimination in Employment Act was established to ban all forms of ageism in firing, hiring, wages, raises, marginal benefits, and other employment features for individuals beyond 40 years of age. However, according to the Equal Employment Opportunity Commission , since 2005, 22% of worker complaints have derived from age discrimination. Of these claims, 25% were centered on not hiring older individuals who felt the positions they desired were offered to younger people . Garstka, Hummert, and Branscombe also discovered in their study on age perceptions that workers of all age cohorts were conscious of the ageist threats made against them. So, what are the consequences of age discrimination? --- The Effects of Age Discrimination Age discrimination can hurt people of all ages. For instance, middle-aged personnel may be denounced for not making progressive career changes to the level believed suitable for their age group . In an industrialized world, however, older workers are somewhat new to the labor market, which is one reason why many companies hire younger workers. Some organizations also hire younger people because they can be trained at lower labor costs. This is what makes ageism so subtle. Older employees often get dissuaded from ensuing job leads. Sometimes, they even get rejected for being overqualified or told there are no job openings . While prior studies focused on discrimination towards older employees and job loss, later research shows that, regardless of their participation, older workers are still underrepresented in the labor market . In fact, between 1960 and 1995, the typical retirement age in the United States fell by roughly four years . Age discrimination can also add detrimental outcomes to a person's financial and psychological wellbeing. According to Chou and Chow , deciding to retire early adversely crashes one's economic circumstance for life. Older workers even encounter difficulty trying to re-enter the workforce after departure, mainly after 60 years of age . Employees over 55 may also go through longer periods without workas compared to younger people. Indeed, younger workers are 40% more likely to receive a job interview as opposed to their older counterparts . By the same token, firing can also worry an older person if attaining a job becomes impossible. Neumark remarks that senior layoffs may result in leaving the workforce forever as their unemployment status goes unreported. In advanced societies, life expectancy is going up, particularly for baby boomersthose born after World War IIwho are now reaching retirement age . McDonald & Potton predict that by 2020, one-third of all adults in many nations will be over 65. This could be due to falling pensions, social security, or company benefits. Chou and Chow further argue that the agenda behind antiage-discrimination has been largely compelled by labor deficiencies and higher costs of social welfare. Rather than attending the needs of older employees, generational equality has been more about cutting social expenditures. --- Age Stereotypes and Stigmatization Negative stereotypes also affect age discrimination. Some people believe older workers are somewhat reluctant or less open to using new technologies. Other stereotypes make people believe that older workers tend to be less flexible; are more likely to neglect change; are less attentive to job tasks; and are not as productive . Older workers may also be denounced for health reasons or underestimated for their expertise if they are perceived as unreliable . Some entrenched beliefs even determine they will become stationary and make progressive planning more difficult. This is why many managers are less supportive in developing their careers. Promotion opportunities appear less in occupations that demand flexibility, originality, and higher enthusiasm, especially since older workers are perceived as less fervent . The aforementioned factors may lead to age stigmaa phenomenon whereby features of marking, typecasting, separating, losing a position, and discrimination occur simultaneously in places that let these practices happen . People who are ashamed of their age may try to hide signs of aging by attending to their physical and mental desires, such as fixing wrinkles through surgical procedures or hair dying. Nonetheless, universities cannot meet the expense of avoiding this issue as aging populations continue to mature and progress among the U.S. higher education workforce. --- Workforce Diversity in U.S. Higher Education Diversity in U.S. higher education is one of the most serious problems fronting the twenty-first century . Under these circumstances, creating work settings that encourage the proficient development of diverse entities and institutions itself turns out to be a concern that must be tackled. Roscigno et al. contends that employment inequities often denote discrimination as a main contributor. Two decades of investigations have even led to the general perception that human capital shortfalls may be the reason why differences in workplace exist . When human capital rules are set, income discrepancies, employment gaps, and imbalances in raises and ability still reside. Higher education is central to these kinds of challenges. While discrimination plays a large role, workplace status plays another. Detrimental employer biases may prevent employing, promoting, and dismissing college faculty. Yet, like churches, universities can be a vehicle for moral growth and charisma . To a certain degree, universities have rooted their mission statements to be accountable for the ethical growth and appeal of all alumnae. As such, they are expected to provide the workforce with skilled hands . Universities are also responsible for enlarging and embracing the development of social diversity on campus grounds. --- Applying Social Closure Theory to Older Faculty in U.S. Higher Education For decades, many older adults have begun finding new occupations on college campuses, whether it is for a second profession or bridge worka place between retirement times . Colleges are undergoing aging in their work environments and are subject to similar prejudices found in other fields. Like any other business, the university is multidimensional; yet, its conventional appearance sometimes has a one-sided vision of academics or does not recognize other layers, such as administrators or staff employees . In a sense, institutions of U.S. higher education may engage in social closure. To begin, a certain number of universities have invigorated faculty and managerial personnel to retire early as a way of drawing younger and untenured employees, and moderating the amount of tenure and salary expenses . Programs set for early retirement are aimed at financially penalizing older workers who are beyond retirement age . Colleges have made changes to accommodate older faculty, especially since their knowledge skills, complete judgment, and hard work may not be cherished in the setting of higher education. Despite the idea that universities are enlightened and leading associations, many of them still support conventional ways, which can negatively affect future changes in employment practices . Looking at older faculty in terms of social closure theory can shed light on how they have been denied opportunities based on their age. --- Young vs. Old and the Tenure Dilemma While the number of professors under 30 years of age increased tremendously from 2005 to 2011, the number of professors 50 and beyond has declined since the 1990s. In 2011, one in five professors was below 30 . The amount of professors above 49 fell from 42% in 2005 to 31% in 2011 . Evidently, older teachers are leaving the workforce as younger ones take on their role. Many face the threat of losing a teaching position based on age alone, particularly if college administrators want to save costs. In 1994, choosing not to promote 317 faculty members to tenure saved over 7 million dollars during that year alone . Tenure means that a professor has a permanent job contract and cannot be fired without a justifiable cause. It is designed to entice talented people to this line of work and protect their free speech rights . Many employers today still frett the idea of lifetime employment. Brosi and Kleiner note that numerous companies still have the misconception that if they hire a younger worker, he or she will remain for a longer time. The route to tenure is a vital component for overall contentment and leaving processes, particularly among women junior faculty . Marschke, Laursen, Nielsen, and Dunn-Rankin contend that existing institutional guidelines are a type of social closure in that they diminish the role of women in all educational domains; indeed, such guidelines fail to discuss the very issues that affect many women. In terms of ageism, this has to do with treating women as if they were inferior because they struggle between finding different ways of balancing home and work duties. It also concerns modifying their way around any changes made in the tenure process . While, in some cases, tenure policies can keep women from climbing up the faculty latter as opposed to their male counterparts, universities must understand that older women often juggle with many differing roles . Similarly, older minorities are also subject to social closure. As such, they experience hardships towards tenure, regardless of gender. Williams and Williams discovered that many African-American male university staff members describe four barriers to achieving raises and tenure: absence of Black senior faculty advisors; absence of knowledge regarding promotion and tenure rules; absence of research endeavor; and the absence of service. These barriers suggest the very notion of social closure, that the university is not hiring enough older African-American professors; concealing certain promotional tips by preserving tenure rules for majority members; granting better research opportunities to younger scholars; and failing to providing substantial support services. Evans and Chun further indicate that minorities may be challenged by the psychosocial dynamic of a department or university in general. Specifically, they emphasize the significance of considering the work setting and the department chair's influence on whether or not a faculty should be granted tenure . Furthermore, college and university administrators are considered somewhat guilty for generating ongoing practices of misusing and taking advantage of part-timers. Several part-time supporters claim that administrators only care about finances, and that there is a financial reason in mistreating poverty-stricken workers . Hiring adjunct faculty implies that, should a financial crisis occur, faculty members reaching retirement age can be plunged from the labor force with the tip of a vice-presidential signature. Other part-time supporters believe administrators only appreciate student rivalry, and if institutions continue recruiting and employing part-time faculty to a higher extent, things will remain stationary. Here, administrators are portrayed as "moral cowards" who inescapably must bulge under "to taxpayers, legislators, parents, students, and [tenured] faculty to keep tuition low and faculty salaries competitive with private business" . When a college department or entity chooses to restrict its recruitment to younger candidates, it differentiates against two groups. In one group, older people who received their PhDs. during the 1970s and 1980s have since held a range of brief and part-time titles. Yet, they want entry-level jobs that extend the leeway to tenure. While many think the number of years of teaching and publishing will grant them a job, professors occasionally find themselves terminated from the interview processbeing labeled as overqualified . In fact, Altbach noted that the increase of aging academics has placed larger burdens on younger PhDs who fight to gain a job by publishing more to reach tenure, regardless of contract quotas. The other group consists of those who are current graduates but who received their doctorate at a late age and are not young anymorei.e., young here means below 40. Even though these applicants have gained experience and were trained the same way as their younger classmates , evidence shows that search committees are sometimes prejudiced towards those who do not match traditional configurations. By removing well-skilled applicants merely for age reasons, search committees lose potential for heartening their departments and institutions. Rank is an objective measure of committee membership, with staff reporting more group affiliations than junior faculty across all organizational categories. While senior faculty describe having more than a quarter of memberships on authority and workforce groups, their participation declines after reaching the age of 50 . Doctoral applicant Sterling Fluhart from the University of Oklahoma found an interesting correlation: those considered top academics are the ones who had completed their PhD in the quickest amount of time after completing their bachelor's degree. Likewise, those who had completed their PhD at a younger age were also considered in the federal data he collected . To put this in perspective, tenured professors at doctoral universities usually obtain a doctorate by age 32; in four-year colleges it is roughly 34; and for a professor at a community college, it is approximately 38 . As this data suggests, the older a person is by the time he or she finishes a dissertation, the less likely he or she will encounter a higher standing occupation. Some may reason that the most efficient graduate students come near the end in a timely manner. If one has the income and opportunity to join a highly selective college for one's four-year degree, begin graduate school quickly after, and then work on the doctorate unceasingly without working for income, then it is assumed that one will mostly likely advance in this vocation. If the situation were reverse, one's PhD may get one something slightly above a low-paying or adjunct position . This further insinuates that candidates who complete a higher education in their mid-30s or take breaks between degrees will most likely be unproductive in academia, which is not necessarily the case. --- Age and Productivity Research shows that age may influence faculty output . In the sciences, age is adversely related to efficient publishing. One notion detained by scientistsand many non-scientists for that matter -is that science is a young person's domain, especially since important scientific inventions have been made by younger researchers . There are several examples that support this belief. At the age of 18, Gauss created the system of least squares; at 29, Darwin came up with the idea of natural selection; Einstein articulated the theory of relativity at 26; and Newton developed calculus and color theory at around 24 years old . While this data shows a correlation between age and publishing, there is little academic data proving that science is only for young people. To further illustrate this delusion, one recent issue in academia is the decline of older Hispanic professors in STEM . In 2003, 36,000 out of 682,000 faculty members were over 65 years old. Within the 36,000, 57% were Hispanic professors 45 and over . These statistics reveal the reluctance that universities have in retaining and advancing Latinos in STEM. Working for the Population Reference Bureau, Mather reasons that there is a gap in educational ranks and practical services among minorities toppled with burdens of the knowledge-based market. Thirty percent of Whites and 48% of Asians above 24 had at least an undergraduate degree by 2004, as opposed to 17% of African Americans and 13% of Hispanics. In addition to this, Hispanics begin school at later times than most other groups The number of occupations held by Blacks and Hispanics in science and engineering fields cannot be accredited to local state shortages in S&E work opportunities. Rather, regions with higher magnitudes of minorities hire more S&E personnel than those that are typically White, particularly because minorities tend to occupy bigger metro zones where S&E professions are mostly focused . Relating this back to the shortage of older Latino science professors, Mather further adds that such a professional dearth in minority communities purports that there are less role models for youth fascinated in chasing science careers. In metro regions, young Blacks and Hispanics tend to live in poverty, experience failure in high school, and face higher unemployment rates . Older Latino professors not only add value to the university with their efforts to publish, give guidance to their in-group, and set an example for troubled youth; they may also be restricted to keep their jobs as social closure processes become more apparent. --- Age and Retirement Ever since mandatory retirements were eliminated from college policy in 1994, many tenured professors were allowed to keep their jobs for life . Departing from the university was anticipated by age 66.6 in 1993 and dropped to 66.2 in 2004. Despite this slight modification, older college staff tend to desire retirement at around 76 years old, especially if they are above 70 . However, Dorfman mentioned that, between 1999 and 2004, the expectation of leaving the workforce by faculty members over 71 went down by four years from 80 years to 76 years . Regardless of an individual's situation, early retirement incentive programs have a persuasive role on their decisions, but not always for the right intention. Since 2000, there have been over 608 staff retirement programs established on U.S. college campuses . To promote and speed up the process of voluntary retirement before 70, 46% of these colleges described having at least one financial inducement, 35% conferred to an acquisition, and 27% had a step-by-step retirement program . Unfortunately, seeing older faculty as a financial burden rather than an asset is still implied in some of these programs. One senior vice provost at Midwestern University said that early retirement meant that colleges were free from spending money on impending enhancements in equipment and supplies. A campus news article also claimed that early retirement programs were launched to substitute leaving teachers with more flexible, low-cost assistant and associate educators . In line with these contentions, faculty retirees are given restricted reemployment opportunities. This entails teaching a course until a replacement found; teaching a subject short of capable instructors; finishing any funded programs; or proceeding as a researcher part-time. Into the bargain, salary is not necessarily based on prior income, and the hours of reemployment are half the amount of full-time recipients . Here, race and gender do not necessarily have to be factors. Many administrators engage in social closure by keeping older staff based on sexual orientation. For example, managing tenure benefits and health costs for heterosexual staff is not an easy task. Indeed, heterosexual employees tend to be more expensive in the sense that they often have to support children and grandchildren. Administrators are more likely to reason that, since older homosexual professors cannot reproduce, they are cheaper to keep on the job as their benefit costs are not as high as their heterosexual counterparts . On the other hand, while anti-gay discrimination has declined over the years, getting health and other perks for a significant other remains a worry for a certain number of older homosexual academics . As compared to heterosexuals, homosexuals are more likely to encounter poor health, loss of companions and support systems, ageism, lower pay, barriers to amenities, lower confidence in finances , and homophobic reactions from healthcare and business professionals . Many universities have distributed a lot of welfare since the 1990s; yet, social closure for this population prevents them from climbing the social hierarchy. As a stigma, being gay becomes less harsh with age because gays and lesbians usually encounter this in younger years . Moreover, people in the GLBT community have a larger capacity for being flexible in gender roles, which can help professors tremendously in the aging process. Although gay relationships have become more tolerable today , substantial discrimination, stigma and blatant disgust toward homosexuals still linger on . --- Discussion and Future Research What this paper has demonstrated is that social closure theory can shed light on how diverse older college faculty members in U.S. higher education can be exposed to discrimination based on their age. As college professors aim to maintain tenured positions, university administrators may reason that younger teachers are less expensive to employ. Tenure policies can also keep older women from climbing up the faculty latter if they struggle between finding different ways of balancing home and work duties. For African Americans, not having enough Black senior faculty advisors shows how universities conceal promotional tips by preserving tenure rules for majority members. Schooling is also correlated with ageism; if a professor finished school beyond the average graduate or took breaks between degrees, he or she is more prone to receiving a part-time position or no interview at all. Social closure theory helps explain why universities avoid hiring and giving tenure to older faculty members. As we have seen, age and productivity coincide with beliefs like "science is for the young," which has kept minorities like older Latino professors from getting hired in STEM fields. It has also prevented them from becoming role models in their communities where youth tend to be troubled. Retirement can also be an ageist process. With many older professors wanting to say in the profession, colleges have used retirement programs as a means of saving costs by replacing elders with younger associate professors. It was interesting to find, however, that although homosexuals are more prone to ageist experiences, they are more likely to keep a tenured statusin comparison with their heterosexual colleagues. Universities reason that benefits to homosexuals are much cheaper because they often remain childless. Nevertheless, older homosexual academics still encounter discrimination, especially when being denied health benefits and other perks. For future research, it would be interesting to see how older college faculty can fight social closure by reversing ageism ethically? For some faculty, the issue is that they have a difficult time knowing how to tolerate stigma, move past prior ageist experiences, or fear failing a job interview based on their age. Nevertheless, older college faculty could use communicative tactics for making the right impression on administrators and/or younger colleagues. In particular, Delery and Kacmar indicated three useful ways for managing impressions in the workplace: prerogatives , improvements , and self-praise . Other studies show that these strategies are more likely to be used when people sense the presence of inconsistencies in the feedback given by their superiors in their workplace . If inconsistencies do take place, individuals may utilize other methods and wait for supplementary comments to direct future dialogues. If more administrators had the courage to speak up on how lowering tuition costs and picking favorites unculturally neglects older faculty, fighting for equality among all aging college employees would be less of a problem. No matter how prevalent ageism towards older college faculty has been, it remains an issue that needs further solutions. For this reason, it is the authors' hope that this analysis based on social closure theory has edified readers on how important it is for this population to advance in the workforce. --- Statements and Declarations --- Declaration of Competing Interest There are no conflicts of interest during the study. --- Disclosure statement No particular disclosure needs to be reported.

This paper examines the effects of ageism on older college faculty in U.S. higher education. Ageism is one of the most socially-accepted types of prejudice; it is a way of stereotyping and discriminating individuals exclusively based on their age group. Social closure theory is the theoretical framework used in this analysis. By and large, the theory rests on the premise that people in their own groups seek to make the most of benefits by limiting access and freedoms to out-group members. Also examined in this analysis are older college faculty from diverse groups: women, African Americans, Latinos, non-traditional graduates, and homosexuals. An important conclusion is that, although science has been viewed as a domain for the young, little evidence exists about the correlation between age and productivity among faculty in U.S. higher education. Therefore, engaging in social closure is not necessary at U.S. colleges and universities.

Background Achieving equitable health outcomes requires approaches that recognise and address the differing levels of advantage people have in society [1,2]. Health inequities are the avoidable, unfair and unjust differences in health between groups of people, which may be defined based on demographic, geographic or socioeconomic factors [1,2]. Ethnic health inequities are those experienced by population groups defined by shared geographic origin and ancestry, and is inclusive of groupings based on "race" that are still commonplace in some jurisdictions [3]. Ethnic health inequities are well-documented globally and many minoritised ethnic groups have poorer health compared to the majority [4][5][6][7][8][9]. In Aotearoa New Zealand , Māori and Pacific peoples experience marked health inequities compared to the majority European population. Life expectancy for Māori is on average seven years lower than for non-Māori [10]. Similarly, life expectancy for Pacific peoples is on average six years lower than for non-Māori, non-Pacific peoples [11]. Māori and Pacific peoples are more than twice as likely to die from potentially avoidable causes as non-Māori, non-Pacific people [12]. There are multiple interacting causes of health inequities, including differential access to and through affordable, quality, culturally safe healthcare, and differential exposure to the determinants of health, e.g. education, employment, income, housing [13,14]. While racism is a determinant of health, it also characterises colonial societies and is a central underlying cause of health inequities for Indigenous peoples [15][16][17]. For Māori, like many other Indigenous populations globally, systematic health inequities are inextricably linked to the historical and contemporary impacts of colonisation [14,18,19]. Māori Health providers in Aotearoa NZ provide 'by Māori for Māori' health services to Māori and others using a kaupapa Māori model with the aim to reduce these impacts. Uptake of health interventions by Māori and other minority groups in Aotearoa NZ is affected by a variety of factors, including social determinants like ethnicity, education and income, [20] as well as patient-clinician interactions and cultural competencies of clinicians and the system [21]. Māori and Pacific peoples are less likely to receive interventions than other ethnic groups, with evidence of this in cancer screening [22], diabetes screening during pregnancy and postpartum [23,24], cardiovascular disease risk assessment [25], vaccinations [26,27] and evidence-based treatments [28][29][30]. We have defined 'intervention' as a broad range of innovations intended to improve human health, including treatments, procedures, programmes and services. Ensuring that implementation pathways are designed to enable equity in outcomes and/or reduce inequity is key to mitigating the inequities associated with intervention implementation. Implementation science studies the influencing factors, methods and processes for systematically promoting intervention uptake into routine practice [31]. Theories, models and frameworks are used in implementation research and practice to explore and identify the factors that influence implementation. They provide guidance for implementation processes, evaluation of implementation outcomes, definition of the scope of implementation research and which constructs to measure. TMFs also support the interpretation of implementation research findings and development of the empirical evidence base [32,33]. Increasingly, TMFs are being developed or adapted to have an equity focus, including identifying the factors that influence equitable implementation, establishing equity-focused implementation processes, and evaluating implementation outcomes with an equity lens and looking at the process of addressing unequitable outcomes [34]. There have been many years of health research that has excluded indigenous communities, and by doing so, this research has contributed to health inequities. By applying an equity lens, we are able to use this approach to ensure that we do not create a model that perpetuates health inequities [35]. Improving health equity has been identified as a priority by the Aotearoa NZ government [36]. In 2014, the National Science Challenges were established to fund mission-based research addressing eleven science-based issues using collaborative approaches, stakeholder engagement and participation, and with the involvement of Māori and mātauranga [37]. One of these Challenges, Healthier Lives, has the mission of reducing the burden of noncommunicable diseases and increasing equitable health outcomes in NZ [38]. In this article, we present one component of a project in the Healthier Lives NSC that aims to support the health system to implement interventions and improve health equity. Adopting a systematic approach to the implementation of interventions is relatively uncommon in Aotearoa NZ, however, utilisation of implementation science approaches to address health inequities is increasing [39][40][41]. In 2017, as part of another Healthier Lives NSC project, Oetzel, Scott and colleagues published the He Pikinga Waiora Implementation Framework to support effective and culturally-appropriate chronic disease intervention implementation for Māori and other indigenous communities, with a focus on co-design [40]. The Framework's authors proposed that He Pikinga Waiora could be used as a planning tool to support intervention development and implementation for researchers, funders and health organisations [40]. He Pikinga Waiora has been operationalised in several studies, including co-designing and evaluating interventions in Māori communities [42][43][44][45][46]. As implementation science approaches become more common in Aotearoa NZ, an identifiable gap in the literature is step-by-step guidance for researchers and practitioners through equity-focused implementation pathway design and delivery. In implementation science, process models provide guidance for how to translate research into practice, usually as a series of steps or stages [19,29]. The aim of this study was to develop an equity-focused implementation framework, appropriate for the Aotearoa NZ context, to support the planning and delivery of equitable implementation pathways for health interventions, with the intention of achieving equitable outcomes. The focus of the development of this framework is on ethnic health inequities, particularly for Māori, as well as its potential application for addressing health inequities for Pacific peoples and other minoritised ethnic or population groups. This framework is primarily intended to support and facilitate equity-focused implementation research and health intervention implementation by 'mainstream' health services/providers . --- Methods The framework development process involved six key steps. Step 1: literature review on equity-focused implementation science TMFs A scoping review of the literature on equity-focused implementation science TMFs was conducted, including TMF components, extent of equity and systems focus and operationalisation. A protocol for the review and the results have been published previously [34,47]. --- Step 2: interviews with stakeholders and researchers in Aotearoa NZ As a part of a broader study, twelve lead or principal investigators who had successfully developed or trialled health interventions and implementation research and thirteen health service leaders, including those who worked in service and management roles in District Health Boards, Māori Health leads, General Practitioners and managers/ directors of non-government organisations, were interviewed about factors they considered to be key in the implementation of interventions that improved equity. The interviews were 40-65 min long and focused on questions related to how Māori are considered in the design and delivery of interventions, and how equity is explicitly considered. The data were analysed using a thematic approach, with initial deductive coding based on a framework developed from the Health Equity Implementation Framework [48] domains and early insights gathered from the interviews. The second inductive stage of coding was guided by Gioia et al. [49] in which team members engaged in the theory building process, identifying themes that helped explain the implementation process for interventions aiming to support equity. Through this process, the first order concepts were examined for commonalities; where commonalities were found they were grouped. This process continued until theoretical saturation was reached [50]. The analysis of the interviews led to 39 first order concepts. Applying Gioia et al. 's method reduced this to fourteen different second order themes, grouped within one of four third order domains. These are presented in Additional file 1. --- Step 3: selection of a TMF to adapt Steps 3 -5 took place at a single-day meeting with members of the research team , which included those with expertise in health equity , Māori health and the Aotearoa NZ health system . The research team reviewed the TMFs identified through the literature search to determine whether adaptation of an existing TMF or development of a TMF de novo was most appropriate. All team members present evaluated the TMF options available and assessed their appropriateness for this study requirements before returning to discuss and decide the appropriate way to proceed, Based on this consensus process the Equity-based Framework for Implementation Research , developed by Eslava-Schmalbach et al. [51], was selected for adaptation. The justification for selecting the EquIR for adaptation was multi-factorial. Firstly, the EquIR is an equityfocused, process-type implementation framework that provides guidance through the entire implementation pathway from design through to evaluation of implementation outcomes. Secondly, the EquIR centres people as the focus of equity-focused implementation research. Thirdly, the framework incorporates the broader contextual factors that are known to influence implementation and health equity directly and indirectly, across a diverse range of sectors and determinants . Finally, it provides a visual representation of the iterative process of design, implementation and evaluation in relation to the target population's health status and the intended outcomes of the intervention being implemented. --- Step 4: adaptation of the framework The adaptation process began by reviewing each step and sub-step of the agreed model sequentially using the expertise of the research team to evaluate its appropriateness and any modifications that were required to meet the study purpose and reflect the needs of the Aotearoa NZ health context. In addition to the He Pikinga Waiora Implementation Framework [40], other implementation TMFs consulted through this process included two determinant frameworks [48] and the Consolidated Framework for Implementation Research [52]) and two evaluation frameworks framework [53] and the equity-focused adaptation of Proctor et al. 's implementation framework [54]). There were several aspects of the framework that we sought to adapt to address the aim of this study. First, the research-focused language was identified as a potential limiting factor for use of the framework in non-research settings. A key aim of our research was to establish a cyclical framework that could be utilised across academic and service settings, and language was identified as a key aspect that could influence its usability. Second, there was a lack of overt consideration of, or prompt for, community engagement and leadership, particularly in the implementation planning phase. Third, absence of 'Implementation' as a clear step; the 'Implementing EquIR' step focuses on designing and defining elements of the research programme [51]. However, having an 'action' step where implementation occurs was identified as useful to encourage active, equity-focused monitoring and feedback while the intervention is being implemented. Fourth, there was no assessment of intervention effectiveness. Incorporating an evaluation of intervention effectiveness in this framework was identified as a key approach to encourage those planning and designing interventions to incorporate assessments of implementation effectiveness alongside intervention effectiveness. Other implementation frameworks, for example RE-AIM, incorporate effectiveness as an outcome measure. Fifth, the inclusion of 'universal health coverage. ' This term is not relevant within Aotearoa NZ as there is a publicly funded health system that provides the majority of healthcare; although it is acknowledged that cost can be a barrier to accessing primary healthcare services due to the existence of a co-payment scheme [55]. --- Step 5: mapping emergent themes from researcher and stakeholder interviews against the adapted framework The emergent themes and sub-themes from analysis of interviews with researchers and stakeholders in the Aotearoa NZ health system context were mapped against the first iteration of the framework to ensure that these were represented. --- Step 6: consultation and iterative revision The first iteration of the framework was presented to the project Kāhui and Consumer Advisory Group. The Kāhui governance group is all Māori and comprised of experts in Māori health research and service provision, as well as Iwi representation. The Consumer Advisory Group comprised of majority Māori health service consumers. These groups are tasked with the responsibility of being co-design partners. They are offered the opportunity to contribute to the design of the tools being developed during regular joint advisory group meetings with the research team. The members of these groups were selected for their experience as practitioners, researchers or consumers in Aotearoa NZ health services. They are governed by Terms of Reference agreed to by each member before their inclusion in the respective groups. These groups provided feedback on the framework components and design, which was then incorporated into a revised version. The second iteration of the framework was presented at a research team workshop where further refinements were made. The third iteration of the framework was developed based on these refinements and additional feedback provided by a research team member with expertise in Māori health research . This version was presented to the Kāhui and Consumer Advisory Group for their input and feedback. --- Results The framework is comprised of five key elements, each is described in further detail below: The foundation is the articles of Te Tiriti o Waitangi ; all aspects of equitable implementation are informed by interpretations of the articles of Te Tiriti. The focus is whānau -centred implementation to achieve equitable outcomes for whānau as a group and for individuals within the context of whānau. The intent is that implementation meets the health and wellbeing aspirations, priorities and needs of whānau. The core constructs are the five key elements that drive equitable implementation and inform each step along the implementation pathway: collaborative design, anti-racism, Māori and priority population expertise, cultural safety and values-based. The contextual factors are the social, economic, commercial and political determinants of health that impact on intervention implementation and health equity. The implementation pathway includes four main steps: Implementation Planning, Designing the Implementation Pathway, Implementation Monitoring, and Outcomes and Evaluation. --- The foundation The foundation of this framework is Te Tiriti o Waitangi, which is the written agreement between Māori rangatira and the British Crown, signed in 1840 [56]. In accordance with the principle of contra preferendum the Māori language version of Te Tiriti takes precedence [57]. An interpretation of the articles of Te Tiriti is expressed in five principles articulated by the Courts and the Waitangi Tribunal [57,58] that apply across the health and disability system and are, therefore, foundational to this implementation framework. The Tiriti principles, their meaning within the 1. This is important because within the Aotearoa NZ health system, health and disability are under the same government appointed commissioner. The intention of this framework is to support mainstream services, as opposed to Indigenous providers, to equitably implement interventions, as an inherent outcome of kaupapa Māori provision is reduced inequities for Māori. Application of the framework in mainstream settings, therefore, relies on putting Te Tiriti principles into practice to drive equitable implementation for Māori. --- The focus As conceptualised by Whānau Ora , the whānau focus of the framework seeks to improve the wellbeing of whānau as a group, and individuals within the context of whānau. Further, the implementation pathway for the intervention should be user-centred, i.e. informed by those with lived experience, and designed or adapted for the context where implementation will occur. Context in this instance refers to the characteristics and circumstances that are relevant to a particular implementation process, including the environmental setting, resource availability and the people involved [52,62]. --- The core constructs The core constructs were identified by the research team, and informed by interviews with stakeholders and researchers, local implementation science literature and feedback from the project Kāhui and Community Advisory Group. These key elements, described in Table 2, are important drivers of equitable implementation within an Aotearoa NZ context. --- The contextual factors Contextual factors are the social, economic, commercial and political determinants of health that impact implementation processes and outcomes and health equity [48]. These influences must be considered in relation to where and to whom the intervention will be delivered and the potential influences on equitable implementation and implementation success. --- The implementation pathway Step 1: Implementation planning Design/Select intervention with implementation in mind This framework assumes that an intervention has already been designed or selected for implementation. This includes new interventions designed to address health inequities, interventions that are being implemented in a new context, and population-wide interventions where there is potential for inequitable implementation. There are various tools available to assist with equity-focused intervention design in Aotearoa NZ, including the Health Equity Assessment Tool Table 2 Core constructs driving equitable implementation pathways in the Aotearoa New Zealand context --- Core construct Description Collaborative design The implementation pathway design is led by, or occurs in partnership with, the community of interest . Participatory processes are embedded, with the type of collaborative approach utilised determined by the type of intervention and the implementation context. Co-creation is an overarching principle that describes a collaborative approach to problem identification and solving, solution implementation and evaluation between diverse stakeholders who are actively engaged and participating at all project stages [63]. Codesign describes the collaborative process between stakeholders to design solutions to pre-specified problems [63]. Co-production describes stakeholder engagement in the implementation of previously determined solutions to previously determined problems, with a focus on how best to use existing assets and resources [63] Anti-racism There is explicit recognition of and efforts to address ethnicity or "race"-based prejudice and discrimination at the level of individuals, institutions and structures [64][65][66]. This includes the examination of power and privilege by individuals and institutions and how this influences intervention design and implementation, and the re-distribution of power, privilege, resources and opportunities to address racism and achieve health equity [40,64,66,67] Māori and priority population expertise Implementation pathway design and delivery is informed by Māori expertise and, if the intervention is being implemented in a priority population , the expertise of that group Cultural safety Self-examination by individuals and organisations involved in the provision of healthcare about the impact of their own culture and biases, assumptions, attitudes, stereotypes and prejudices on clinical interactions and healthcare provision, and actions to address these, with a clear goal of achieving health equity [68] Values-based Explicitly articulate and reflect the guiding principles and beliefs of the intervention's priority or target population , as determined by that population [69], the Equity of Health Care for Māori framework [70], Whānau Ora Health Impact Assessment [71] and the He Pikinga Waiora Implementation Framework [40]. Key considerations prior to implementation include: • Reach: Who is invited, included, participating and engaged in the intervention design and implementation process, and who may be missing [54]. The people who are invited, included, participating and engaged should mirror the population intended to benefit from the intervention and context where implementation will occur [54]. • Access: How the priority population accesses the intervention and any potential barriers to this. Here we have adopted the broad conceptualisation of access as defined by Levesque and colleagues, which includes five dimensions: 1) approachability, 2) acceptability, 3) availability and accommodation, 4) affordability, and 5) appropriateness [72]. [54,73,74]). Equity-focused intervention design and adaptation will include meaningful engagement with, and involvement of, community leaders and people with lived experience , with these processes being community-led where possible. Community engagement has been demonstrated as an important determinant of implementation effectiveness in Indigenous communities [75][76][77]. --- Identify and involve key stakeholders for implementation Identify key stakeholders required to ensure equitable implementation, e.g. health professionals, patients and their whānau, community and organisational leaders, community and organisational champions, other stakeholders [51]. Stakeholders should be involved through the subsequent steps. --- Identify barriers and facilitators to equitable implementation Identify factors that could influence equitable implementation of the intervention, either positively or negatively [51]. This typically requires engagement with stakeholders and other information gathering processes, e.g. document searches, analysis of local data. An equity-focused determinant framework [48,78] or another determinant framework with an equity lens applied could be utilised to guide this process. Determinant implementation frameworks identify the factors that enable or inhibit implementation across a range of domains that describe micro-, meso-and macro-level factors [32]. --- Identify measures of implementation and intervention effectiveness The specific measures that will be monitored and assessed in the subsequent steps to determine effectiveness of the intervention and the implementation pathway. Identifying outcome measures prior to implementation ensures that the pathway design is fit-for-purpose and that the impact of implementing the intervention, based on the selected outcomes, can be evaluated [51,54]. --- Step 2: Designing the implementation pathway Design communication strategy with equity in mind Good communication within and between organisations enables knowledge about barriers and facilitators to equitable implementation, strategies and outcomes to be shared [79][80][81][82][83][84]. The strategy should also include mechanisms for two-way communication between those implementing the intervention and the priority population, and consideration of the ability for patients and their whānau to process, understand and navigate health information and services to engage with the intervention [79]. Define resources required for equitable implementation Resource availability is a key determinant of implementation success [79]. Resourcing for equitable implementation may require different approaches to the setting where evidence of effectiveness was demonstrated. For example, adequate and flexible funding to enable community-based providers to undertake targeted delivery strategies to reach the priority population [79,83,85], or adequate numbers of staff who reflect the population served, have the relevant skillset and provide culturally safe care [76,79,80,85]. The type of resources will depend on the intervention and implementation context, but will likely include consideration of staffing and other workforce development, intervention-specific training, cultural safety training, physical resources and financial resources [79]. Design equity-specific strategies to address barriers Design strategies to overcome barriers to equitable implementation identified in the previous step. This may include strategies to overcome accessibility barriers for whānau, implementing cultural safety training for staff, or workforce development strategies to prevent burnout of Māori staff. Design monitoring and evaluation metrics Establish intervention and implementation pathway-specific measures that will be monitored and evaluated in subsequent steps, including what data will be collected, how it will be analysed and evaluated, and how these results will be shared with stakeholders and utilised while implementation is ongoing. Consideration should be given here to the value of priority population expert input to enable measurement that is robust from priority population perspectives. --- Step 3: Implementation monitoring Measuring and monitoring implementation outcomes determined in the previous steps with an equity lens, which may include some or all of the implementation outcomes presented in Table 3. Alternatively, another evaluation framework could be selected , with an equity lens applied [86]. For users undertaking Indigenous community-based research, the He Pikinga Waiora Implementation Framework [40] could be used to evaluate outcomes related to community engagement, cultural centredness, integrated knowledge translation and systems thinking; the Framework's User Guide provides instructions and a guide for conducting evaluation across these dimensions [87]. --- Step 4: Outcomes and evaluation Implementation effectiveness Evaluation of implementation outcomes as per the implementation outcomes measured in the previous step. Intervention effectiveness Evaluation of effectiveness, as per the measures established in the previous step. Any intervention or implementation pathway adaptations Evaluation of any specific equity and/or adaptation metrics. Assess overall pathway for inequity causes, solutions and accountabilities Overall assessment of the intervention's implementation pathway, including review of any inequities that were identified and the causes, potential solutions and recommendations for adjustments to the pathway and determination of who is responsible and accountable for implementing the changes. --- Discussion This paper presents an equity-focused implementation framework that is intended to support the design and delivery of equitable implementation pathways for health interventions in Aotearoa NZ. This framework provides step-by-step guidance through the process of undertaking equity-focused implementation research for health programmes, services, and systems [51]. The focus of this adapted framework is on addressing ethnic health inequities, with an initial focus on those experienced by Māori in Aotearoa NZ. It may also have relevance for other Indigenous peoples and other minoritised ethnic or population groups, such as Pacific peoples. Equitable delivery of health interventions is essential to achieving equitable health outcomes. Conversely, inequitable delivery increases the likelihood that the benefits will not be fully realised for all who are receiving, or intended to receive, the intervention, and may lead to worsening inequities. Equitable implementation ensures the provision of interventions, programmes and services in a fair and just manner that recognises and accounts for systemic social disadvantage and injustice experienced by minoritised population groups [89,90]. Equitable implementation is said to occur when key equity aspects, including culture, history, values, assets and community needs, are explicitly integrated into implementation science processes, tools and strategies [91]. Process frameworks guide the user through the steps or stages that are needed to translate evidence into routine practice [32]. Few implementation process models are explicitly equity focused [34], although this is changing as the field of implementation science is increasingly attentive to health equity [89,[92][93][94]. Our framework is intended to complement the He Pikinga Waiora Implementation Framework, the first implementation framework to be developed for the Aotearoa NZ context, by incorporating the key elements of successful and culturally appropriate intervention implementation identified as relevant to Māori and other Indigenous populations [40]. Adaptation was determined to be appropriate for this study given that, overall, the EquIR conceptual framework provided a clear representation of many aspects that were relevant to meeting the aims of the research. The adapted framework expands on EquIR by incorporating the relevant principles of Te Tiriti o Waitangi as well as refinements that ensure this framework is useable across research and service settings. This included • Who is not reached by the intervention and why? • How can those who are eligible for, but not receiving, the intervention be reached? --- Feasibility Extent to which a new intervention can be successfully used or carried out in a given setting • Does the intervention allow for health equity barriers to be reduced? • What is the practicability of implementing the intervention in a given setting, especially among priority populations? • What adaptations are required to improve feasibility of intervention implementation for the priority population? Fidelity Degree to which an intervention was implemented as originally described or intended • To what degree is the intervention delivered as intended? • To what degree is implementation equity-focused as originally intended? --- Implementation cost Costs associated with an implementation effort • What is the cost of implementation in priority populations ? Are the implementation costs equitable? • What is the final adjusted cost-effectiveness evaluation? --- Sustainability Extent to which a newly implemented intervention is/can be maintained as part of a service's routine operations • Is the intervention being equitably maintained/sustained? • In which settings and populations is the intervention being sustained? Do all settings/populations have the capacity and partnerships to sustain intervention delivery? • Are the benefits of the intervention being sustained? Are the sustained benefits equitable? If not, why? • Are health inequities reduced or increased by adaptations to the intervention? • Which strategies could ensure the maintenance, continuation, durability/embedding or scale up of the intervention in the priority population? revisions to the foundation of the framework by grounding it in Te Tiriti o Waitangi and Te Ao Māori concepts, and the change of language to be less research-focused. Additionally revising the implementation outcomes to include prompts of equity considerations in relation to the established implementation outcome definitions ensures that the framework can be applied in multiple settings and across diverse population groups. --- Strengths This study presents an exemplar of the process for adapting an international equity-based implementation framework for the local context in collaboration with an Indigenous advisory group and consumer advisory group. The adapted framework is informed by the international implementation science literature on equity and implementation success and incorporates local lessons learned from health equity researchers and stakeholders. The framework is designed to be used in partnership with existing equity tools and approaches, for example, the He Pikinga Waiora Implementation Framework; this offers users the flexibility of incorporating tools and approaches that stakeholders are already familiar with. --- Limitations As this is a conceptual study, the framework has not been tested and empirical evidence validating its benefits is not yet available. Understanding how the framework performs in practice is an important next step to advancing implementation science in Aotearoa NZ. Additionally, some of the contextual specificity of this framework may limit its use in other populations. In particular, Te Tiriti o Waitangi as the foundation of equitable implementation processes is unique to the Aotearoa NZ context. The evidence informing the framework focuses on addressing ethnic health inequities, particularly those experienced by Māori in Aotearoa NZ. However, this framework could be adapted for use in other population groups who experience health inequities, such as other Indigenous peoples and other minoritised ethnic or population groups. Prospective users in other jurisdictions should be informed by the foundational principles that are relevant to the implementation context or priority group that is intended to benefit from use of the implementation framework. --- Future directions Operationalisation of this framework in intervention implementation will be important to determine its effectiveness and usefulness in both research and service settings. It is possible that additional refinements may be needed based on the outcomes of the framework's performance in practice. Furthermore, incorporating an assessment of 'equity readiness' for services and/or organisations prior to implementing an intervention is likely to be beneficial. As part of the broader research programme, we have developed an equity readiness assessment tool that can be used alongside the framework for equity-focused implementation work. We envisage this framework being used by teams planning the implementation of interventions for a variety of ethnic and minority groups, for example the disability sector and LQBT + . Reflection and adaptation may be required to ensure the appropriateness to other groups. --- Conclusion The framework presented in this study is the first equityfocused process-type implementation framework that has been adapted for the Aotearoa NZ context. The framework is recommended for use by health researchers, service providers and other stakeholders to support the systematic design, delivery, monitoring and evaluation of equitable implementation pathways for health interventions, programmes and services. Future research is needed to determine the effectiveness of utilising this framework to reduce inequities in intervention implementation and achieve equitable outcomes for Māori, Pacific peoples and other minoritised ethnic and population groups. --- --- Abbreviations --- --- --- Competing interests The authors declare no competing interests. ---

Background Health intervention implementation in Aotearoa New Zealand (NZ), as in many countries globally, usually varies by ethnicity. Māori (the Indigenous peoples of Aotearoa) and Pacific peoples are less likely to receive interventions than other ethnic groups, despite experiencing persistent health inequities. This study aimed to develop an equity-focused implementation framework, appropriate for the Aotearoa NZ context, to support the planning and delivery of equitable implementation pathways for health interventions, with the intention of achieving equitable outcomes for Māori, as well as people originating from the Pacific Islands. Methods A scoping review of the literature to identify existing equity-focused implementation theories, models and frameworks was undertaken. One of these, the Equity-based framework for Implementation Research (EquIR), was selected for adaptation. The adaptation process was undertaken in collaboration with the project's Māori and consumer advisory groups and informed by the expertise of local health equity researchers and stakeholders, as well as the international implementation science literature.The adapted framework's foundation is the principles of Te Tiriti o Waitangi (the written agreement between Māori rangatira (chiefs) and the British Crown), and its focus is whānau (extended family)-centred implementation that meets the health and wellbeing aspirations, priorities and needs of whānau. The implementation pathway comprises four main steps: implementation planning, pathway design, monitoring, and outcomes and evaluation, all with an equity focus. The pathway is underpinned by the core constructs of equitable implementation in Aotearoa NZ: collaborative design, anti-racism, Māori and priority population expertise, cultural safety and values-based. Additionally, the contextual factors impacting implementation, i.e. the social, economic, commercial and political determinants of health, are included.The framework presented in this study is the first equity-focused process-type implementation framework to be adapted for the Aotearoa NZ context. This framework is intended to support and facilitate equity-focused implementation research and health intervention implementation by mainstream health services.

Introduction During the COVID-19 pandemic, older adults experienced increased risk of hospitalisation and death [1][2][3][4], but the complete scope of impacts of the pandemic is not yet understood. Public health measures implemented to decrease virus transmission also had unintended negative physical and mental health consequences [5]. Because older adults disproportionately experienced severe disease and death during the pandemic, age-based measures to reduce risk were frequently implemented [6], but chronological age alone does not fully account for the heterogeneity in vulnerability between age groups [7]. Frailty, a multidimensional syndrome associated with increased vulnerability to stressors, predicts multiple adverse outcomes in community-living [8] and inpatient populations [9]. It is a stronger predictor than age of healthcare utilisation [10] and receiving informal care [11]. Although some studies have used a 'frailty lens' to examine health impacts of COVID-19, most have focussed on the direct impact of COVID-19 on mortality in hospitalised patients [12][13][14][15] or long-term care residents [16,17]. Frail older individuals with less reserve to respond to external stressors are more susceptible to developing psychological distress and social isolation [18], which increased with COVID-19-related restrictions [6,19,20]. Although people living with frailty may have had the greatest healthcare needs during the pandemic, they also experienced challenges accessing both in-person and virtual healthcare [21][22][23], which likely increased demands on informal caregivers. During the first COVID-19 wave, home care visits decreased [24] and informal care provision grew [25]. Although caregiving has many positive aspects, the increase in demand coupled with difficulties in accessing needed healthcare led to greater caregiver stress, depression and a lower sense of well-being that sometimes strained relationships with carerecipients [26]. Studying a large population-based sample of older adults categorised by their frailty level may help identify subgroups more vulnerable to the noted health and social impacts of the COVID-19 pandemic. We analysed data from a COVID-19 questionnaire administered to participants in an existing population-based longitudinal study to examine whether pre-pandemic frailty was associated with health, resource, relationship and/or healthcare access impacts experienced during the COVID-19 pandemic. We hypothesised that participants with higher frailty levels would more often report impacts. In previous work, we demonstrated that frailty is related to age, sex and income [27]. We also explored whether the impact of frailty level was modified by these factors. --- Methods --- Study design/setting The Canadian Longitudinal Study on Aging is a comprehensive research platform collecting data on health and ageing [28]. Baseline data were obtained on 51,338 participants in 2011-2015. Participants are seen in 3-year cycles for up to 20 years. The first followup was completed on 48,893 participants in 2015-2018. In response to the COVID-19 pandemic, a questionnaire-based addition to the main study was launched on 15 April 2020. These COVID-19 questionnaires were administered at weekly to monthly intervals via phone or web with the final contact taking place between 29 September-29 December 2020 . The COVID-19 study was approved by the research ethics boards of participating institutions. Data from the CLSA baseline, FUP1 and COVID-19 questionnaires were used. --- --- Research paper Sites located across Canada and underwent both inhome interviews and local DCS visits where additional data were collected. Of 51,338 initially enrolled participants, 42,511 were still active in the CLSA at the launch of the CLSA COVID-19 study, 28,559 agreed to participate and of them 24,114 completed the COVID-19 Exit survey. In total, 23,974 of this group also completed their FUP1 assessment. This group included 121 participants reporting a positive COVID-19 test or being told they had COVID-19 by a healthcare professional . Given our primary interest was assessing the impact of frailty on living through the initial days of the pandemic and accompanying public health response irrespective of infection status, both COVID-19 positive and negative participants were included in our primary analyses. In sensitivity analyses, we examined COVID-19 as a covariate . Compared with the CLSA cohort at FUP1, those completing the COVID-19 Exit survey were less likely to have a household income <$50,000 and more likely to live in a rural setting and be a non-drinker . --- Variables --- Frailty index A frailty index was constructed using standard criteria from a range of health deficits assessed at FUP1 [29,30]. Deficits were recoded as '0' if absent and '1' if present. For non-binary variables, a gradient from 0 to 1 was created using equal steps. Each participant's FI value was the sum of deficits present divided by the total number of deficits considered. Since the deficits differed slightly for tracking and comprehensive participants, we calculated cohortspecific FI quartiles to harmonise the cohorts with 1 representing participants with the lowest FI scores and 4 with the highest FI scores . This allowed us to examine gradients in prevalence of COVID-19-related impacts by frailty severity. Descriptive statistics for 85 deficits comprising the FI for tracking and 76 for comprehensive participants are presented in Appendix 2a and 2b. --- COVID-19 impacts At the COVID-19 Exit survey, participants were asked if they experienced any of several potential impacts during the pandemic. For this paper, we examined health impacts , resource impacts and relationship impacts . Participants were further asked if they had experienced any challenges accessing healthcare during the pandemic. If yes, they were asked if these healthcare access impacts were for: primary care, specialist care, prescription medications, pharmacist, diagnostic testing, screening tests or a delay in surgery. Finally, to better understand barriers to healthcare access, participants were asked if they were unable to use videoconferencing technologies or had no access to a computer. --- Covariates We examined if impact by FIQ differed by participant sex , age at COVID-19 Exit survey and prepandemic annual household income in Canadian Dollars . Prepandemic covariates used for adjustment were chosen based on the frailty literature [31,32] and included: marital status , smoking status , nutritional risk , social participation restriction due to health limitations, living alone and low physical activity [34]. --- Statistical analysis The association between FIQ with each COVID-19 impact was estimated using logistic regression. Unadjusted models included FIQ alone and adjusted models included FIQ and all covariates. Predicted prevalence with 95% confidence intervals was estimated for each COVID-19 impact by FIQ using the unadjusted and adjusted logistic regression models. We also examined the gradients of these prevalence estimates across FIQ quartile). Finally, interaction effects were used in the logistic regression model to examine if the gradients of FIQ differed by age, sex or pre-pandemic household income. As the models can be unstable when outcome prevalence is low, interaction analysis was done only when the impact prevalence was at least 1% in one of the FIQs. To interpret statistically significant interactions, we plotted the predicted impact prevalence across FIQ for each age, sex or income subgroup. As a sensitivity analysis, the final interaction models were re-run including COVID-19 status as a covariate. Although the amount of missing covariate data was relatively low , we speculated that frailer participants might have more missing data. Furthermore, due to administrative reasons, a subset of cognitive tests was not conducted in the comprehensive cohort during the first months of FUP1. Multiple imputation was conducted using predictive mean matching to provide estimates less prone to bias [35]. We investigated the number of burn-in iterations for stability of the imputed data and used 40 iterations for the imputed data sets. We further implemented 10 imputed data sets and evaluated the efficiency of the imputations. We Current/former daily smoker used Rubin's rule for pooling the parameters of the logistic regression models. The method for combining P-values of the significance of factors was adapted from Fisher's approach [36]. We chose this method because it is conservative when Chi-square statistics are positively correlated [36]. All analyses were conducted using SAS version 9.4 [37] and R version 4.1.0 [38]. We used the Strengthening the Reporting of Observational Studies in Epidemiology checklist when drafting this manuscript [39]. --- Results --- --- Pandemic impacts and frailty quartiles Table 2 presents unadjusted and adjusted prevalence estimates by FIQ and gradients ) for COVID-19 health, resource and relationship impacts. Other than loss of income , there was an increasing prevalence gradient for all COVID-19 impacts with participants at higher frailty levels more often reporting impacts. The most commonly reported adverse impact was family separation, which was reported by over 50% of participants. The largest absolute difference between prevalence in FIQ4 and FIQ1 in adjusted analyses was 13.3% for being ill, 7.4% for increased verbal or physical conflict and 7% for being unable to access necessary supplies. Increasing FIQ was associated with increased healthcare access challenges . The largest gradients between FIQs were found for the overall measure of any healthcare access challenge . --- Influence of age, sex and income Interaction analyses were conducted for all impacts except access to a pharmacist because of its low prevalence . Statistically significant interactions are presented in Figures 123. For age, there was a statistically significant interaction for one health impact , one relationship impact and for all healthcare access impacts except prescription medications . Other than surgical delays and barriers using videoconferencing technologies, the oldest age group generally had the lowest overall prevalence of impacts and the smallest increases in prevalence across FIQs. The youngest age group experienced the highest prevalence of most impacts, especially for those most frail . This was especially evident for challenges accessing specialist care and diagnostic testing. There were significant interactions between FIQs and sex for resource impacts, loss of income and four of the eight healthcare access impacts . Loss of income FI gradient is the change in prevalence for each FI quartile compared with the first quartile a In addition to age, sex, and income all models are adjusted for marital status, living alone, social participation, smoking status, physical activity and nutritional risk was similar between sexes in FIQ1 but was experienced more often by males than females in FIQ2-4. For specialist care, prescription medications and surgery delay, the access challenges were similar for FIQ1-FIQ3 and higher for males than females in FIQ4. As for diagnostic testing, males had more access challenges in FIQ1, whereas females had more in FIQ4. The difference in estimated prevalence between males and females for all in healthcare access impacts was 2% or less. There was no statistical evidence that the effect of FIQ on health impacts or healthcare access differed by income category. There were for resource impacts and all three relationship impacts . Although there was no clear pattern with respect to income, the lowest income group seemed to deviate from the other income groups, especially for lowest FIQ. Including COVID-19 status as a covariate had no substantive impact on the results except for the sex by frailty quartile interaction for access to screening, which became statistically significant with a larger gradient over FIQ for females compared with males . --- Research paper Figure 1. Estimated adjusted prevalence of health, resource, relationship and healthcare access impacts experienced during the COVID-19 pandemic for logistic regression models with a statistically significant interaction between FIQ and age group . Interaction models are adjusted for sex, income, marital status, living alone, social participation, smoking status, physical activity and nutritional risk. --- Discussion Community-living adults with higher levels of pre-pandemic frailty reported not only more negative health impacts, but also resource, relationship and healthcare access challenges during the first year of the COVID-19 pandemic in Canada. The gradient across frailty levels was not explained by sociodemographic or health behaviour factors and generally increased after covariate adjustment. The association between FIQ and some COVID-19 pandemic impacts differed among subgroups. Most strikingly, the association of FIQ with healthcare access impacts differed across age groups. These data suggest relatively younger participants with higher frailty levels were more likely to be impacted negatively. After family separation, the most commonly reported pandemic-related impacts were health and resources . Although others have reported increased health-related impacts in frail adults with COVID-19 [12,40], none have examined loss of income related to frailty. The frailty gradient for loss of income appeared only in adjusted analyses, which may be explained by the strong association between frailty and age and the inverse relationship between age and income loss during the pandemic [41]. The breakdown in family relations showed a 5.7% absolute and 185% relative increase in FIQ4 compared with FIQ1 after adjusting for all other covariates. Possibly this was related to reduced formal home care support during the pandemic increasing the burden on family carers [24][25][26]. The prevalence of most impacts was lowest for the oldest age group and highest in the youngest with the differences in prevalence across age groups increasing with greater frailty severity. This was especially true for specialist visits and diagnostic tests where the difference in adjusted prevalence between the youngest and oldest age group was negligible for FIQ1 and 15.6 and 13.9%, respectively, higher in FIQ4. Younger participants with higher frailty levels appeared more likely to be impacted by the pandemic, but the underlying reasons for this are unknown. Lower healthcare access challenges in the oldest subgroup may also reflect the low prevalence of participants reporting challenges accessing videoconferencing and the increased use of telehealth for routine care. In the US, telehealth visits increase by 154% from March 2019 to March 2020 [42]. In Ontario, virtual care increased from 1.6% of all ambulatory visits in the second quarter of 2019 to 70.6% in the same period in 2020 [43]. Although there are known sex differences in frailty [44] and healthcare utilisation patterns [45], we did not find that the effect of FIQ on healthcare access differed greatly by sex. Moreover, there were no statistically significant interactions with prepandemic household income. This is consistent with a study that found very few European countries showing significant income-related inequalities associated with unmet healthcare needs [46]. Older participants reported a lower prevalence of being ill with a less steep gradient across FIQs than the other age groups. This may reflect greater adherence to public health recommendations and cocooning found in older adults [6]. However, loss of income was similar between males and females in FIQ1, males with higher levels of frailty reported this more often than females. However, there was no consistent pattern for interactions between pre-pandemic household income and resource impacts, although the lowest income group showed differences from other income groups. This could reflect a larger impact from the loss of paid carers in these groups [25,26]. More research would be needed to understand these interactions. --- Strengths and Limitations Using an existing national population-based cohort, we examined the health and social impacts of the COVID-19 pandemic on middle-aged and older adults with differing degrees of frailty. The large sample size allowed investigating how the impact of frailty level differed across subgroups based on age, sex and income. This reinforced that not all subgroups of the population experienced pandemic impacts equally. --- Figure 2. Estimated adjusted prevalence of health, resource, relationship and healthcare access impacts experienced during the COVID-19 pandemic for logistic regression models with a statistically significant interaction between FIQ and sex . Interaction models are adjusted for age, income, marital status, living alone, social participation, smoking status, physical activity and nutritional risk. A limitation of the CLSA is that participants are largely white, well-educated and economically advantaged. Furthermore, the response rate of the COVID-19 Exit survey was 56.4%. Participants with lower income were less likely to participate in the study, limiting generalisability to more economically marginalised populations. Our results may also be sensitive to the deficits and cut-points utilised in the FIs. However, we constructed the index using a standard approach [30], validated it in a separate publication, and have used it to explore the social underpinnings of frailty in another study [27,47]. We chose to use quartiles instead of a single cut-point so we could examine gradients across a range of frailty severity. Finally, we chose a conservative method to estimate P-values across the imputed datasets and may have underrepresented significant interaction effects. --- Clinical and public health implications Understanding the health-related impacts of both the COVID-19 pandemic and the public health response on older people have been identified as research priorities [48]. Additional enquiry is needed to elucidate how measuring frailty can inform prevention and care [49]. We found frailty gradients not only for health but also resource, relationship and healthcare access impacts during the pandemic. Younger old rather than mid to older old reported the greatest access Figure 3. Estimated adjusted prevalence of health, resource, relationship and healthcare access impacts experienced during the COVID-19 pandemic for logistic regression models with a statistically significant interaction between FIQ and pre-pandemic household income in Canadian dollars . Interaction models are adjusted for age, sex, marital status, living alone, social participation, smoking status, physical activity and nutritional risk. impacts especially for healthcare and at higher levels of frailty. Although frailty, instead of age, has been endorsed as a tool to estimate COVID-19 prognosis [12,40,49], our data suggest that it may have a broader role in primary care and public health to identify those who may benefit from interventions to reduce the health and social impacts of COVID-19 and future pandemics.

Background: frailty imparts a higher risk for hospitalisation, mortality and morbidity due to COVID-19 infection, but the broader impacts of the pandemic and associated public health measures on community-living people with frailty are less known. Methods: we used cross-sectional data from 23,974 Canadian Longitudinal Study on Aging participants who completed a COVID-19 interview (Sept-Dec 2020). Participants were included regardless of whether they had COVID-19 or not. They were asked about health, resource, relationship and health care access impacts experienced during the pandemic. Unadjusted and adjusted prevalence of impacts was estimated by frailty index quartile. We further examined if the relationship with frailty was modified by sex, age or household income. Results: community-living adults (50-90 years) with greater pre-pandemic frailty reported more negative impacts during the first year of the pandemic. The frailty gradient was not explained by socio-demographic or health behaviour factors. The largest absolute difference in adjusted prevalence between the most and least frail quartiles was 15.1% (challenges accessing healthcare), 13.3% (being ill) and 7.4% (increased verbal/physical conflict). The association between frailty and healthcare access differed by age where the youngest age group tended to experience the most challenges, especially for those categorised as most frail. Conclusion: although frailty has been endorsed as a tool to inform estimates of COVID-19 risk, our data suggest it may have a broader role in primary care and public health by identifying people who may benefit from interventions to reduce health and social impacts of COVID-19 and future pandemics.

Introduction Throughout the world there is a shortage of donor organs to meet the demand for transplantations. In the US there are currently over 110,000 people on the waiting list for a solid organ transplant and 18 people per day die awaiting an organ . Similarly, in the UK there are currently over 10,000 people waiting for a solid organ transplant and 3 people die per day awaiting a donor organ . Moreover, the situation is getting worse, with the number of people awaiting an organ increasing each year . Previous research has found that nextof-kin have considerable influence over whether the deceased's organs are donated in both presumed and informed consent countries . In many countries, medical professionals will not transplant organs if family members oppose transplantation, even when there is no legal obligation to receive family member's consent because the deceased is a registered organ donor. Indeed, researchers have argued that the availability of donor organs may be substantially increased by preventing family members from vetoing their deceased loved one's decision to be an organ donor . Moreover, even when a loved one's wishes are not recorded a considerable number of potential donors are being lost because family members do not consent to donation. For example, in 2010, 43% of UK families refused when asked if their loved one's organs could be used for transplantation purposes . It is, therefore, important to identify the factors that promote and prevent family members from donating their loved one's organs in order to increase the number of donor organs, thereby saving lives. Previous research has focused on the rational, cognitive factors that guide next-of-kin's decision making. For example, research has found that donation was more likely when family Running Head: NEXT OF KIN DONATION 4 members understood the concept of brain death , knew the deceased's wishes , and had positive attitudes towards organ donation . Recent organ donor registration research has found that emotional or affective factors are stronger predictors of people's intentions to register and registration behaviour than rational, cognitive components ). Although donating one's organs and consenting for a family member's organs to be donated are separate actions, they are both influenced by similar factors . The aim of the present study was, therefore, to extend previous research by determining whether such emotional and affective factors predict family member's willingness to donate a loved one's organs. --- The role of affective factors on organ donation Recent research has found that people's affective attitudes are likely to guide decisions relating to organ donation . These affective attitudes include the anxiety associated with the belief that the body should be kept whole for burial , fearing that doctors may hasten the death of seriously ill patients in order to harvest their organs , feeling disgust towards the idea of organ donation , fearing that organ donors may not be resurrected because they do not have all of their 'parts' , and the positive arousal associated with the belief that organ donors are heroic because they save lives . Research in the US and the UK has found that registered organ donors are less likely than non-registered participants to feel the negative emotions towards donation and endorse these negative beliefs, and are more likely to believe the positive consequences of organ donation. Moreover, further research has found that the more non-donors endorse the negative affective attitudes, the less likely they are to subsequently register as an organ donor . To date, this research has focused on the role of affective attitudes in promoting organ donor registration. The first aim of the present study was to enhance previous research by assessing the role of these beliefs on the decision of whether or not to donate a loved one's organs. It is likely that the greater the participant endorses bodily integrity and jinx concerns, and the ick factor the less likely they will be to donate their loved one's organs. By contrast, perceived benefit beliefs are likely to increase the likelihood of family members donating their loved one's organs. Medical mistrust is most likely to affect the decision to donate before the loved one has died because family members may believe that doctors may not do everything possible to save the life of their loved one. By contrast, when the decision is made after the family member has passed away medical mistrust is less likely to affect the decision to donate their organs. Another affective factor that has been linked to organ donation is anticipated regret ). Regret is an aversive counterfactual emotion that is likely to be experienced when people wish that they had acted differently in the past . Research has found that family members may later experience regret for their decision regarding whether or not to donate a loved one's organs, especially if they refuse to donate . This implies that regret is relevant in the decision regarding whether or not to donate a loved one's organs. It is also possible to anticipate the amount of regret that is likely to be felt for failing to undertake an action, providing people with a pre-emptive strategy for avoiding this aversive emotion . For example, research has found that anticipating regret for not registering as an organ donor increase people's willingness to register and self-reported registration . The present study extents this research by assessing whether anticipating regret for refusing to donate a loved one's organs increases people's willingness to consent to donation. Another important factor is whether or not the participant is a registered organ donor . As mentioned above, registered organ donors are less likely than non-registered participants to feel the negative emotions towards organ donation and endorse the negative affective attitudes, and more likely to believe the positive consequences . Based on this research, we hypothesised that registered organ donors would be more willing than non-registered participants to donate their loved one's organs and that this effect would be mediated by their affective attitudes towards organ donation. Moreover, because registered organ donors are more likely than people who are not registered to support organ donation, registered donors are likely to anticipate greater levels of regret for not donating a loved one's organs. The desire to avoid this regret may motivate people to consent to donation. The relationship between the participant's organ donor status and their willingness to donate a loved one's organs may, therefore, also be mediated by anticipated regret. --- Present study The aim of this study was to determine the affective factors that promote and prevent people from consenting for their loved one's organs to be used for transplantation purposes. Approaching family members who have recently lost a loved one is likely to cause excess distress. Because of this ethical issue, we decided that it would not be appropriate to contact such families. Previous research has avoided this ethical issue by using vignette studies . In line with this, we used a vignette study to assess our hypotheses. Participants were asked to imagine that a close family member had died and that they had been asked to decide whether his/her organs could be used for transplantation purposes. Previous research has found that the deceased's attitude to organ donation is an important predictor of whether or not family members consent to donation . We, therefore, also assessed the role of the deceased's organ donation status on people's willingness to donate a loved one's organs. Participants were either a) given no information about this , b) informed that their loved one was a registered donor , c) told that their loved one was not a registered donor , d) informed that their loved one had not registered because they had concerns about bodily integrity , or e) told that their loved one had agreed with donation but that they had not registered . 1 The distinction between active and passive non-donors was made to determine whether people's willingness to donate a deceased non-donor's organs is affected by the reason why the deceased was not registered. Indeed, in opt-in systems inaction may be ambiguous because it may represent either an objection to organ donation or that someone failed to undertake the action required to show their consent, despite the fact that they were willing to donate their organs. --- Method --- Participants and design A total of 191 undergraduate students participated in this study in exchange for course credit. The age range was 17-64 years, with a mean of 20.77 . Eleven participants did not state their age. There were 90 registered organ donors and 101 participants who were not registered as an organ donor prior to completing the study. The percentage of registered organ donors in the study was slightly higher than that of the Scottish general public . The participant's organ donor registration status was a quasi-independent variable. The deceased's organ donor status was experimentally manipulated. Participants were randomly assigned to one of the five experimental conditions. The study, therefore, used a 2 x 5 between participants design. The dependent variables were the total number of organs and body parts donated, anticipated regret, and people's affective attitudes towards donation . --- Materials and procedure After giving consent, participants stated whether or not they were a registered organ donor. Next, they were then asked: "Please imagine that a close family member has passed away and that you have been asked to decide whether his/her organs may be used for transplantation purposes". We then manipulated the deceased's organ donor registration status. Participants in the control condition did not receive any information about the deceased's organ donor status. Participants in the donor and non-donor conditions were asked to imagine that the deceased was or was not a registered organ donor, respectively. Participants in the active non-donor condition were asked to imagine that the deceased was not a registered organ donor because they did not like the idea of having his/her organs removed from his/her body. Participants in the passive nondonor condition were asked to imagine that the deceased approved of organ donation, but that they had not registered. Running Head: NEXT OF KIN DONATION 9 Total number of organs donated. Participants were asked to rate whether or not they would donate their loved one's heart, lungs, kidneys, liver, pancreas, small bowel, eyes, skin, bones and heart valves. A dichotomous response was provided for each body part . We summed the total number of body parts that the participant was willing to donate. 2 This variable indicated people's general willingness to donate their loved one's organs. Anticipated regret and affective attitudes. Anticipated regret was then measured using two items: 'If I did not allow my loved one's organs to be used for transplantation purposes I would feel regret' and 'If I did not allow my loved one's organs to be used for transplantation purposes I would later wish that I had' . Both items were rated on a 7-point Likert-type scale . Participants then rated their affective attitudes towards organ donation using an established scale . Bodily integrity is measured with 2 items . Medical mistrust is measured with 4 items . The 'ick factor' is measured with 3 items . Jinx is measured with 3 items . 3 Perceived benefit is measured with 4 items . All items were rated on a 7-point Likert-type scale . Once participants had completed this scale they were debrief and thanked. --- Results --- Total number of organs donated The number of organs donated ranged from 0 to 10, with a mean of 7.08 . This mean was significantly greater than zero, t = 29.73, p < .001, indicating that people Running Head: NEXT OF KIN DONATION 10 were generally willing to donate their loved one's organs. A 2 x 5 ANOVA was conducted on the total number of organ's donated. The total number of organs donated was greater for participants who were registered organ donors than those who were not registered , F = 12.19, p = .001, ηp 2 = .07. The main effect of the deceased's donor registration status was significant, F = 3.30, p = .012, ηp 2 = .07. Post-hoc analysis revealed that fewer organs were donated when the deceased was an active non-donor than when the deceased was a donor , a non-donor , or a passive non-donor . Active non-donors also donated fewer organs than participants in the control condition , but this difference was non-significant . The interaction between the participant's and the deceased's donor status was non-significant, F = 0.83, p = .508, ηp 2 = .02. --- Affective attitudes towards organ donation A 2 x 5 ANOVA was performed on the affective attitudes to determine whether they varied between conditions. The deceased's registration status did not have a significant effect on any of the affective attitudes . The participant's registration status had a significant effect on all 5 affective attitudes. Bodily integrity concerns were lower for registered organ donors than non-registered participants , F = 22.69, p < .001, ηp 2 = .11. Similarly, registered organs donors were less concerned about medical mistrust than non-registered participants , F = 12.31, p = .001, ηp 2 = .06. The ick factor was lower for registered than non-registered participants , F = 30.79, p < .001, ηp 2 = .15. Registered organ donors were also less concerned about jinx than non-registered participants , F = 15.04, p < .001, ηp 2 = .08. Finally, registered organ donors endorsed the perceived benefits of organ donation to a greater extent than non-registered participants , F = 14.07, p < .001, ηp 2 = .07. These results reflect the fact that registered organ donors were less likely than non-registered participants to feel the negative emotions and endorse the negative affective attitudes, and were more likely to believe the positive consequences of organ donation. The interaction of the two independent variables did not have a significant effect on any of the affective attitudes . --- Anticipated regret A 2 x 5 ANOVA was conducted on the measured anticipated regret variable to determine whether it varied between conditions. The main effect of the deceased's registration status was non-significant, F = 1.56, p = .186, ηp 2 = .03. The mean level of anticipated regret was greater participants who were registered organ donors than those who were not registered , F = 27.95, p < .001, ηp 2 = .13. These results reflect the fact that registered organ donor are more likely than people who are not registered to anticipate regret for not allowing their loved one's organs to be donated. The interaction between these independent variables was non-significant, F = 0.44, p = .783, ηp 2 = .01. --- Mediation We assessed whether the main effect of organ donor registration on willingness to donate was mediated by anticipated regret and the affective attitudes . As mentioned above, the participant's organ donor registration had a significant effect on the mediators and on the dependent variable , fulfilling the first two criteria for mediation . Crucially, the main effect of the participant's registration status on donation became nonsignificant when these mediators were entered into the original regression equation . In this analysis, the significant predictors of the number of organs donated were anticipated regret , the ick factor , jinx , and perceived benefit . Bodily integrity was a marginally significant predictor of the number of organs donated . Interestingly, medical mistrust did not uniquely predict the number of organs donated . The lowest tolerance value was .43, indicating that the dataset was not biased by multicollinearity . Moreover, this model explained 42% of the variance in the number of organs donated, F = 17.79, p < .001. The significance of the indirect pathways from registration to donation, via anticipated regret and the affective attitudes, were assessed using 95% bias-corrected and accelerated confidence intervals, calculated using 5000 bootstrap resamples . In this multiple mediator analysis the confidence intervals did not include zero for the indirect effect through anticipated regret , the ick factor , jinx , and perceived benefit , indicating significant indirect effects through each of these variables. The confidence intervals for the indirect effects through bodily integrity and medical mistrust included zero , indicating that these indirect pathways were non-significant. These results reflect the fact that registered organ donors are more likely to donate their loved one's organs in comparison to people who Running Head: NEXT OF KIN DONATION 13 have not registered because they anticipated greater regret, are less likely to feel disgust towards donation, and are more likely to endorse the positive consequences of donation. Registered organ donors are also more likely than non-registered donors to endorse jinx beliefs. However, contrary to previous research and our expectations, we found that jinx, in turn, positively predicted donation. --- Discussion The aim of this research was to examine the factors that promote and prevent organ donor registration. We extended previous research ) by demonstrating that the affective factors that guide organ donor registration also guide the decision of whether or not to donate a loved one's organs. Registered organ donors were more likely than non-registered participants to anticipate regret for not donating their loved one's organs and endorse the perceived benefits of donation, and were less likely to feel disgust towards organ donation and have concerns about jinx. These affective factors, in turn, predicted the number of their loved one's organs that the participant was willing to donate. In line with previous research we found that people were reluctant to donate their loved one's organs when they believed that he/she disagreed with organ donation. In the active non-donor condition participants were informed that the deceased opposed donation because of bodily integrity concerns. It would be interesting to assess whether people are also reluctant to donate a loved one's organs when the deceased endorsed the other negatively valenced affective attitudes . This question was beyond the scope of this study, but should be considered for future research in this area. Running Head: NEXT OF KIN DONATION 14 Conventional organ donation campaigns aim to increase registration and donation by providing people with rational, cognitive arguments. For example, campaigns often provide people with the statistics relating to the number of people waiting for a solid organ donor and the number of these people who die waiting for this transplant. This research supports previous findings in suggesting that organ donation campaigns may be more effective if they target the affective attitudes and factors that guide decision making. For example, research has found that simply asking people whether they would accept an organ from a deceased donor in order to save their own life increases people's willingness to register as an organ donor by decreasing their concerns about bodily integrity . Such research suggests that the UK NHS Blood and Transplant's campaign that included such reciprocal primes are likely to be effective and should be used to increase organ donation. However, rigorous evaluation of campaigns that target people's affective attitudes are also urgently required. Previous research has found that a simple anticipated regret manipulation increases people's intentions to register and the likelihood that the participant will register as an organ donor . We enhance this work by demonstrating that anticipated regret also influences the decision of whether or not to donate a loved one's organs. It could, therefore, be argued that anticipated regret interventions should be created to increase people's willingness to donate a loved one's organs. However, this study only found that anticipated regret partially mediates the relationship between the participant's registration status and the number of organs donated. Further research is required to determine whether such manipulations may be implemented to increase organ donation by next-of-kin in people who are registered and not registered as an organ donor. Importantly, previous research has found that family members are unlikely to donate their loved one's organs when they feel pressurised . It is, therefore, important to ensure that any such intervention does not cause families to feel pressurized as this could have a detrimental effect on donation. It is also worth noting that jinx positively predicted the number of organs donated after controlling for the participant's organ donor registration, the other affective attitudes and anticipated regret. A marginally significant negative correlation was found between jinx and number of organs donated, supporting our expectations. The fact that this relationship became positive in the regression analysis suggests that jinx negatively predicted donation through the other affective attitudes and that removing this variance resulted in a positive correlation. Although this finding is interesting, future research is needed to determine whether it is reliable and, if so, the mediating process through which it occurs. In the present research we found that even when the deceased was an organ donor, there was no increase in people's willingness to donate their organs. This may have been due to the fact that the deceased's attitude towards organ donation was not explicitly stated. Indeed, previous research has found that people are more willing to donate their loved one's organs when they believe that the deceased had a positive attitude towards donation . We may have found an increase in people's willingness to donate their loved one's organs if a positive attitude towards donation was also presented. Moreover, this highlights the importance of discussing organ donation with loved ones and its positive effect on family member's willingness to donate their loved one's organs . As mentioned above we used vignettes to assess the factors promoting next-of-kin donation. The use of this methodology allowed us to experimentally manipulate the deceased's organ donor status in order to assess causal relationships. Moreover, this methodology allowed us to avoid the ethical issue posed by contacting family members who had recently lost a loved one. There are also some disadvantages with this methodology. The main disadvantage was that the situation was not real. As a result, it may be argued that the factors outlined above may not predict organ donation by next-of-kin in the real-world. However, there are numerous reasons to suggest that the results may be applicable to the real-world. First, as mentioned above, interviews with family members who have decided whether or not to donate a loved one's organs has found that regret may be associated with this decision . The fact that anticipated regret was found to predict next-of-kin donation in the present research, therefore, corresponds with this real-world research. Similarly, the validity of this vignette study is also supported by the fact that the deceased's opinion about organ donation influenced people's decisions in the present study and previous real-world research . It could be argued that the relationship between the affective attitudes and organ donor registration is due to cognitive factors, such as the factor proposed by the theory of planned behavior . Although the affective attitudes are related to attitude and subjective norm, they are stronger predictors of organ donation behavior that these cognitive factors . Because of this, it is more likely that the effect of such cognitive factors may be partly due to the affective attitudes than vice-versa. Although there was a wide age range in this study, the mean age of participants was approximately 20 years. Therefore, the vast majority of participants were young adults. Moreover, a large proportion of participants were female. Therefore, it is worth considering the effect of such demographics on the results of the study. Research has found that people's willingness to donate their own or a loved one's organs is not predicted by gender , suggesting that the large proportion of females is unlikely to have affected the results of this research. However, age negatively predicted both of these organ donation variables , thereby suggesting that young adults are likely to support organ donation. Moreover, young adults are less likely to have experienced their next-of-kin passing away. However, as mentioned above the results correspond with interviews that were conducted with family members who have decided whether or not to donate a loved one's organs . This suggests that the results of the present study are likely to be applicable to other populations, such as older adults. In conclusion, this study extends previous research ) by demonstrating the role of the deceased's and next-of-kin's organ donor status and affective factors on people's willingness to donate their loved one's organs. We found that registered organ donors were more willing than non-registered participants to donate their loved one's organs and that this effect was mediated by anticipated regret and their affective attitudes towards organ donation. This research highlights the importance of developing organ donation campaigns that target anticipated regret and the affective attitudes in order to decrease the likelihood of family members refusing to donate their loved one's organs. --- Conflicting Interests No conflicting interests. --- Footnotes 1 We also manipulated anticipated regret by informing participants in the regret condition that previous research had found that families who donated their loved one's organs were less likely than families who refused to donate these organs to regret their decision. However, this manipulation did not have a significant effect on our anticipated regret manipulation check, F = 1.22, p = .271, ηp 2 = .01. We, therefore, do not mention this manipulation further. This manipulation was included as a covariate in the analyses outlined below. --- 2 We also analyzed people's willingness to donate each specific organ. The findings of these analyses were similar to those presented. We, therefore, decided to avoid repetition by simply presenting the results for the total number of organs donated. 3 Removing items from this scale did not improve its reliability.

This research assessed whether affective factors promote and prevent family members from donating their loved one's organs. Participants (N = 191) imagined that a family member had died and that they had to decide whether or not to donate their organs and body parts for transplantation purposes. The least organs and body parts were donated when the deceased opposed donation. Moreover, participants who were not registered organ donors donated fewer organs than registered donors. This effect was mediated by anticipated regret, disgust, and the perceived benefits of donation. Organ donation campaigns should target such factors to increase donor rates.

I. INTRODUCTION Al-Islam and Kemuhammadiyahan learning is mandatory material at Muhammadiyah/Aisyiyah Higher Education. This is by the mandate given by PP Litbang Dikti Muhammadiyah. In other words, PTM is a higher education institution that stands for protecting all groups. The hope is that alums will always live up to Islamic and Muhammadiyah values in various activities. Such as the value of justice , the importance of caring for others , the value of being friendly and not being hostile to each other and being willing to knit togetherness . The final achievement of the AIK course is expected to make students, indirectly, ambassadors of religious peace born from PTM. As reflected in AIK's educational goals, namely, to form human beings with noble character, excel in science, technology and progress . Amidst the diversity of ethnicity, race and religion, the existence of Al-Islam and Kemuhammadiyahan is currently experiencing new challenges, especially the implementation of Al-Islam and Kemuhammadiyahan in Muhammadiyah Higher Education, whose student base is from various religions, ethnicities and races . As happened in the Papua region. Muhammadiyah tertiary institutions in the region are dominated mainly by non-Muslim students. In order to unify these differences, a container is needed that can accommodate all the existing differences. So that the differences that occur do not cause conflict . Islam Wasathiyah is sometimes only centred on moderate Islamic movements that aim as a solution to the problem of religious conservatism known as the extreme left and the extreme right . This illustrates an incomplete understanding. The purpose of religious moderation is not only mediation between those who tend to have ultraconservative religious views, however, as a group with liberal religious views, attitudes and behaviour or what is commonly known as the extreme left . Even in a multicultural society, as in Indonesia, religious moderation exists as a counterweight in people's lives. This balance is essential because, of course, Allah created everything in this world in pairs . First, the existence of AIK teaching makes Education at Muhammadiyah one of the Islamic organizations with the main characteristics of an education system. Furthermore, Al-Islam is a work of improvement in Islamic religious education in which the main subjects of Islam are contained, including the teaching of Al-Qur'an Al-Hadith, Aqidah, Morals and Muamalah. As for what is referred to as Muhammadiyah Worship, there are certain ideological teachings and the history of Muhammadiyah which trace the existence of Muhammadiyah from the beginning to the present . Second is the superiority regarding Muhammadiyah administration management, better known as the collegial collective leadership model. This advantage has become one of the secrets of success and survival in management. Conceptually, the collegial collective model is based on personal principles or only one character. Apart from that, it also offers opportunities to implement justice in organizations, such as the principle of distributive justice, procedural justice, interpersonal justice and the right to information. Third, Persyarikatan Muhammadiyah cadres are those who run Muhammadiyah educational institutions. Persyarikatan Muhammadiyah Cadres are the main actors of the organization with the soul, attitude, thinking, understanding, personality and competence as agents or subjects of Muhammadiyah da'wah at all levels of society. Therefore, Muhammadiyah cadres must constantly be tested and trained in all their human dimensions. So that Muhammadiyah can develop its mission now and in the future. Universitas Muhammadiyah Sorong is a Muhammadiyah college serving the city of Sorong, West Papua. Since its establishment, this university has been concerned about educating indigenous Papuans. Even the enthusiasm of native Papuan students is also outstanding. This can be seen from the stable new student admissions data, which even increases yearly. The tendency of the number of students to continue their education at the Universitas Muhammadiyah Sorong proves its success in placing an attitude of religious moderation on its students . In contrast to Muhammadiyah higher education institutions in general. Universitas Muhammadiyah Sorong, most students are native Papuans who are non-Muslims. Based on initial observations, an average of 27 students were in one class, and 19 were non-Muslims . This is what makes the Universitas Muhammadiyah Sorong called a multicultural campus . This certainly raises academic anxiety because the number of non-Muslim students who are more dominant in Muhammadiyah tertiary institutions will undoubtedly affect the treatment of their students . The results that non-Muslim students feel can accept the Muhammadiyah movement well. This can be seen when, on duty, non-Muslim students sing the song Sang Surya without coercion, even though the song contains monotheistic messages for Muslims. Another impact is changing the behaviour of non-Muslim students about Muhammadiyah in Sorong City. This can be seen from the social interaction of students. Non-Muslim and Muslim students, in making friends, are not picky. --- II. METHOD The research in this study uses a qualitative approach. To understand the primary phenomenon studied in research, researchers and research sites. This type of research uses case studies, meaning the research carries out in-depth studies of individuals, groups, organizations and action programs. Data collection techniques are divided into 4 types. The observation technique referred to in this research is that researchers are involved so they can understand their behaviour and activities. Interview between the researcher and the resource person/appointed body, in this case, the researcher and the Chancellor, as well as AIK lecturers and students. The documentation method collects data needed in research through variables, which can be in the form of notes, transcripts, books, newspapers, magazines, writings, minutes of meetings, and agendas. The objects observed in this research are documents related to the AIK teaching model based on religious moderation. The data analysis technique is carried out in several steps: Data condensation, data presentation and conclusion drawing. In this dissertation, to test the validity of the data, the researcher used triangulation, namely, data obtained through specific methods and sources compared with other methods and sources. Researchers can ask research subjects they carefully examine the integrated description of the search for the meaning of life and can make additions or corrections . --- III. RESULT AND DISCUSSION Based on the results of the interviews, the implementation of Al-Islam and Kemuhammadiyahan learning based on religious moderation at Sorong Muhammadiyah University is planned at the beginning of each new school year, namely during an academic workshop. The activity brought together all the lecturers and discussed the curriculum related to AI-Islam and Kemuhammadiyahan learning. In addition, lecturers are also required to prepare a semester lesson plan, which will then be conveyed to the study program. --- Figure 1. Implementation of Al-Islam dan Kemuhammadiyahan --- Implementation of Learning Based on Religious Moderation The documentation of student activities and interviews show that implementing Al-Islam and Kemuhammadiyahan learning based on religious moderation at Universitas Muhammadiyah Sorong is implemented through several non-academic activities and does not have credits. The activities in question are as follows: --- Matras Al-Islam Kemuhammadiyahan's learning is based on religious moderation outside of classroom learning. It is carried out through non-academic activities starting from the new student admissions period before the first semester lectures begin each year. This activity involves actors and various resource persons, persons in charge, directors or supervisors related to AIK teaching at Universitas Muhammadiyah Sorong All. New students at Muhammadiyah Srong University, both Muslim and non-Muslim, are required to take part in the student ta'aruf period program for seven consecutive days from 07.00 to 17.00 WIT. Based on the observations of researchers and explanations of research subjects and informants, new students in this opportunity get material about higher education culture, academic skills, personality, leadership, and social skills. Thus, Islamic values have been designed to be integrated into the intended materials. Separately or at different times, new Muslim students, apart from being required to take part in the Matras program, as mentioned above, are also required to participate in the Darul Arqam Dasar training program. Based on the results of the researchers' observations, it is known that Mattress activities are carried out before entering the new school year or when students are still prospective new students . The speakers presenting the Mattress material are campus actors such as the Academic, Administration, Data Center, and Al-Islam and Muhammadiyah sections. --- Darul Arqam Dasar This program was carried out a few days after the Matras activity. It was carried out for four consecutive days, during which Darul Arqam Dasar participants had to stay on campus during the activity. New students on this occasion receive basic materials on Al-Islam and Kemuhammadiyahan, coaching on reading and writing the Qur'an. Furthermore, students who still need to read the Qur'an are given the task of studying it once they can and are given one semester. Students who can read the Al-Qur'an well Academic Workshop program implementation lectures programs are tasked with guiding a maximum of five of their friends who still need to read the Al-Qur'an so that they can read it for at least one semester. Based on researchers' observations, implementing DAD activities at the Universitas Muhammadiyah Sorong is similar to implementing learning activities in class. The difference is that the executor of this activity is the Commissariat of the Muhammadiyah Student Association Muhammadiyah Sorong University, carried out in a short time and does not include the type of academic activity with credit weights. The learning methods used in these activities vary greatly. Almost all methods, starting from lectures, discussions, questions and answers, demonstrations, games, and field practice, were used in this activity. Evening meditation, which can be interpreted as muhasabah, is a form of evaluation activity carried out at the end of the entire series of DAD activities. --- Christian Student Fellowship The Sorong Christian Student Fellowship is a forum for non-Muslim students to conduct social activities according to their beliefs. Even though the association was not legal or was not founded directly by Muhammadiyah Sorong University. However, the student response was high because non-Muslim students are most at Muhammadiyah Sorong University. PMK activities are more of a weekly service at a church not far from campus. Other routine activities are fundraising for victims in need and social service activities, which are also held at the church. In addition to on-campus activities, PMK activities also involve the unity of the Se-Sorong Raya community, which involves activities and the larger community. --- Seminar The seminar activities referred to here are seminar activities that can accommodate Muslim and non-Muslim students. This seminar is a routine activity organized by the Al-AIK institution, Muhammadiyah Sorong University. This activity involved a committee of Muslim and non-Muslim students and presented speakers from Islam and Christianity. --- Field Study Field study activities are integrated with the AIK III course. Implementation of the field study: Students are divided into two groups and given group assignments. Each group consists of 4-5 people. Groups are separated according to their respective religions. Muslims with Muslims and non-Muslims with non-Muslims. The main activity of the field study assignment is to provide experience for students to have an attitude of social spirituality by their respective beliefs. This activity aims to foster students to have an attitude of religious moderation . --- Mabit Activities The --- IV. CONCLUSION The study results revealed that the implementation of Al-Islam and Kemuhammadiyahan learning was generally carried out with two learnings, namely learning in and outside the classroom. The integrative learning model popularized by Forgatry is teaching that combines more than one subject by combining various ideas and skills). Moreover, attitudes are then combined from each subject of teaching. The point is intentionally or specially designed teaching so that some aspects of teaching curricular activities are taught. Through this integration, students will gain complete knowledge and skills to make teaching activities more meaningful.

This research explores the application of Al-Islam and Kemuhamadiyahan learning based on religious moderation. This research uses a qualitative approach with a case study type of research. Data collection by observing, interviewing and documenting. Data analysis using the interactive model popularized by Miles and Huberman includes data condensation, presenting data and drawing conclusions. Testing the validity of the data using triangulation techniques: time triangulation, source triangulation, method triangulation, and investigator triangulation. So, this research found that implementing Al-Islam and Muhammadiyah learning was based on religious moderation. The results of this research are that implementing AI-Islam and Kemuhamadiyahan learning based on religious moderation is generally carried out with two types of knowledge, namely learning in and outside the classroom. Classroom learning by implementing AIK education guidelines at PTMA and AIK Multicultural. Meanwhile, activities outside the school are integrated with campus activities, namely Matras, Muhammadiyah Student Association (IMM), Tapak Suci (TS), Christian Student Association (PMK), seminars, field studies, mabit activities and seminars. The AI-Islam and Kemuhamadiyahan learning model based on religious moderation is one form of operationalization of the ultimate goal of Islamic education, namely empowering humans. Penelitian ini bertujuan untuk menggali penerapan pembelajaran Al-Islam dan Kemuhamadiyahan berbasis moderasi beragama. Penelitian ini menggunakan pendekatan kualitatif dengan jenis penelitian studi kasus. Pengumpulan data dengan melakukan observasi, wawancara dan mendokumentasi. Analisis data dengan model interaktif yang di populerkan oleh Miles dan Huberman meliputi kondensasi data, menyajikan data dan penarikan kesimpulan. Pengujian keabsahan data dengan teknik triangulasi: triangulasi waktu, triangulasi sumber, triangulasi metode, dan triangulasi penyidik. Sehingga hasil dari penelitian ini menemukan implementasi pembelajaran Al-Islam dan Kemuhammadiyahan berbasis moderasi beragama. Hasil penelitian ini adalah Implementasi pembelajaran AI-Islam dan kemuhammadiyahan berbasis moderasi beragama secara umum dilakukan dengan dua pembelajaran yakni pembelajaran di dalam kelas dan diluar kelas. Pembelajaran di kelas dengan penerapak pedoman pendidikan

Introduction Premature implies babies born alive before 37 weeks of gestation. Based on gestational age, premature birth is sub-categorized as extremely premature , very premature , and moderate to late premature [1]. Premature babies are prone to severe illness or death during the neonatal period. Even those who survive are at increased risk of lifelong disability and poor quality of life if appropriate care is not provided [2]. There are simple solutions to reduce deaths among premature babies at home in the lowest income settings, such as early and exclusive breastfeeding, handwashing, chlorhexidine application, and skin-to-skin care. Premature babies need extra warmth and support for feeding than others [3,4]. Worldwide, 15 million babies are born prematurely annually, indicating a global premature birth rate of about 11%. Premature birth complications are the leading cause of under-5 child mortality, accounting for 18%. Besides, 35% of neonatal mortality is also due to prematurity or premature complications globally [1,5,6]. The burden of premature birth is high in low-and middle-income countries, especially those in Southeast Asia and sub-Saharan Africa [5]. More than 60% of premature births occur in Africa and South Asia. Within countries, poorer families are at higher risk [1]. Pocket studies in Ethiopia indicated that the prevalence of PB ranged from 4.4% to 16.5% [7][8][9][10][11]. The 3/4 th of these deaths could prevent with current and costeffective interventions [1]. More attention is needed for premature babies in low and middle-income countries. Myths, misconceptions, and negative attitudes make premature births invisible and slow prevention and care efforts [12,13]. In addition, most community members rely on local newborn illness diagnoses and traditional medications. This has a negative impact on people's willingness to seek medical care for their babies [14]. As shown in qualitative studies from Ghana and Malawi, the perceived causes for premature were categorized into maternal and general social factors. The commonly stated maternal factors were teenage and pregnancies in advanced maternal age, history of abortions and premature birth, prolonged use of family planning method, extramarital sex, sexual impurity, heredity, maternal illness during pregnancy, imbalanced diet, overworking during pregnancy, and husband beating. The general social factors, such as witchcraft and the use of local medicine during pregnancy, were also identified as causes of premature birth [15][16][17]. One study also suggested that almost all participants recognized an etiology conceptualization and disease framework for premature birth and distinguished premature birth from miscarriage and macerated stillbirth [1]. Components of care for premature newborns include keeping them warm by using cloth, plastic bottles and hot water bags, squeezing breast milk, and maintaining good hygiene [16]. Other studies also recommend that all premature newborns should be kept warm [3,18]. The most common challenges to caring for premature newborns were lack of knowledge on how to provide care, poverty, and the high time burden of care, which led to neglect of household, farming, and business duties. Women were mainly responsible for caring for premature newborns [16]. A qualitative study conducted in Canada identified mothers who faced difficulty with breastfeeding, failing to recognize infant feeding distress and disorganized behavior, and the parental stress caused by the multiple feeding issues [19]. In Ethiopia, studies have assessed the prevalence, determinants, and causes of death for premature babies in health facilities and communities [7][8][9][10][11]18]. However, these studies do not explore how the community perceives the cause, recognition, and care of premature babies, or the challenges they face. Therefore, this qualitative study aimed to fill these research gaps in the study setting. --- Materials and methods --- Qualitative approach, research paradigm, and context This interpretive Husserlian phenomenological study was conducted in Arba Minch zuria and Gacho Baba district, Arba Minch-Health and Demographic Surveillance Site , southern Ethiopia, from January 1 to 30, 2022. Arba Minch-Health and Demographic Surveillance Site was established in 2009 in collaboration between Arba Minch University and the Ethiopian Public Health Association with the support of the Centers for Disease Control and Prevention Ethiopia to track demographic changes. The surveillance site includes nine kebeles, selected from the 29 kebeles located in Arba Minch zuria and Gacho Baba districts, Gamo Zone, southern Ethiopia. Arba Minch is an administrative town in the Gamo Zone, located 505 km south of Addis Ababa and 275 km southwest of Hawassa. Based on the 2007 Census conducted by the Central Statistical Agency , these districts have a total population of 164,529, of whom 82,199 are men and 82,330 are women. According to the HDSS report, there is a total population of 74,157 in the surveillance site. --- Sampling strategy A purposive sampling method was employed to recruit focus group discussants and key informants. Women with premature babies in less than one year, grandmothers and grandfathers who gave care for premature babies, and men with premature babies in the study setting were selected for focus group discussions . Traditional birth attendants , traditional healers, women, and men were key informants for the in-depth interview . The number of FGDs and IDIs to meet the objective of this study was determined by idea saturation . --- Data collection methods This study used IDIs and FGDs to collect data. An interview guide was used to collect qualitative data. The interview guide was developed based on the expert opinion, knowledge, and skill of investigators and existing works of literature. The interview guide covered socio-demographic characteristics of study participants, questions on perceived causes of premature birth, how the community recognizes or identifies premature babies, care for premature babies, and challenges in caring for premature babies. This study involved two moderators and two observers for FGDs, and two interviewers for IDIs. Overall, two supervisors were recruited to supervise all FGDs and IDIs. All the moderators, observers, interviewers, and supervisors had at least a master's degree in health-related discipline and previous experience in qualitative data collection. After completing a preliminary session of data collection, including training moderators, observers, interviewers, and supervisors, and pre-testing the interview guide, study participants were traced and advertised with the help of local leaders to recruit them for the study. Then, consent was obtained from those who were willing to participate in this study. Participants who were essential to meet the study objectives were purposively selected by the team and recruited to either FGDs or IDIs. Initially, either the observer or interviewer documented the background information of each participant. The interviews and discussions were held in the participant's homes and open spaces in the village, which was comfortable for the participants. Each FGD and IDI session was recorded using an audio tape recorder. The moderator briefly introduced the team members, explained the study aim, and gave participants the opportunity to ask clarifying questions before initiating the discussion. The discussion was held until idea saturation was reached, or for a maximum of one hour, whichever came first. The moderators controlled the entire discussion and the observers took key notes and recorded all information from the FGDs on the spot. In-depth interviews were held only by the interviewer. --- Trustworthiness, researcher characteristics and reflexivity Trained and experienced moderators, observers, and interviewers conducted the data collection. The data collectors communicated and discussed daily about any challenges they faced during the data collection period. A well-established, expert-commented, and reviewed interview guide was used to collect the data. Participants with relevant expertise and experience were selected to ensure the trustworthiness of the data. The investigator maintained a neutral view and probed participants to elicit more detailed information. Data credibility was achieved by involving key informants with different social statuses to capture a variety of perspectives and by re-checking original audios and written transcripts to develop themes. NVivo 12 Plus software was used to maintain connections between participant descriptions and the researcher's interpretations, thereby achieving conformability. The results were presented alongside direct quotes from participants. The transcripts, translations and demographic summary of participants were maintained, and keynotes were taken during and after the interview to achieve the dependability of standards [20]. --- Data collection type Number of participants In-depth interview of the mother with a premature baby 4 In-depth interview of the father of a premature baby 2 In-depth interview of the TBA 2 In-depth interview of the traditional healer 2 Focus group discussion with the mothers of premature babies 11 Focus group discussion with the fathers of premature babies 8 Focus group discussion with the grandmothers 7 Focus group discussion with the grandfathers 6 https://doi.org/10.1371/journal.pone.0294155.t001 --- Data analysis The collected FGD and IDI audio recordings that were transcribed verbatim in the local language were independently listened to multiple times by the two investigators until they were familiar with the participants' information. Then, the two investigators translated the qualitative data into English transcripts, compared them, and resolved any discrepancies. The investigators read and reread the transcripts to familiarize themselves with the participants' ideas and to develop memos and codes line by line against the themes and subthemes of the framework. They refined and compared the codes for newly emerged themes and subthemes, and discussed their findings daily until they reached agreement on the inconsistencies, new ideas, emerged themes, and subthemes. Data collection continued until idea saturation was reached. Data were analyzed inductively using a thematic content analysis approach with the qualitative data analysis software NVivo 12 Plus [20]. --- --- Results In this qualitative study, 42 participants, including 32 FGD discussants and 10 key informants, were involved. The median age of participants were 42 years old. Out of the participants, 25 were female, and 16 were not educated, and 3 , 12 , and 11 were read and write, primary, secondary, and above respectively. In general, seven main themes and twenty-six sub-themes emerged . --- General concept Definition for premature babies. The majority of FGD discussants and IDI key informants defined premature babies as babies born before completing the ninth month. Participants reported that if the mother delivers before the seventh month or at the seventh month and the baby is not alive, it is called abortion "bosha". The majority stated that babies delivered in the eighth month may not survive. ". . .premature baby means a baby delivered in the seventh month. We know premature birth, as we count the dates starting from the date of cessation of menses and if the baby delivered before the ninth month. . ." . ". . .if the mother gives birth before the seventh month it is called "bosha" or abortion, if at seventh month and the baby is alive we called that premature baby. If the baby is delivered in the eighth month, the baby cannot survive. After giving birth, I observed my baby, and I told to my mother why we took this premature baby to our home and does this baby will grow. My mother also refused to take my baby when we were discharged from the hospital. We also informed the Doctor to throw the baby in the toilet, but the Doctor counseled us, and we decided to take it home." . The difference with low birth weight babies. Almost all participants differentiated premature newborns from low-birth-weight babies. They stated that a low-birth-weight baby is only small or weak, but healthy and delivered after completing the ninth month of pregnancy. Even though premature babies are small and weak, they may be unable to suck and breastfeed. A few participants were unable to differentiate premature babies from low-birth-weight babies. "The difference between premature and low birth weight babies is that the low birth weight is small and weak but healthy and delivered after completing the ninth month of pregnancy. Nevertheless, the premature baby is also small and unable to suck the breast, as it is immature." . "As to me, we cannot differentiate premature newborns from low birth weight baby rather than the health professionals." . --- Perceived causes for premature birth Unknown cause. A few participants said that they did not know the exact causes of premature birth, but they shared some community perceptions of the causes. --- ". . .I have a son delivered in the seventh month, but now the baby grow. Nevertheless, I do not know the exact cause for premature delivery." . --- ". . .the community has different perceptions on the causes of premature birth, but we do not know the exact causes for premature delivery." . Maternal factors. In this study, most discussants and key informants stated that premature birth can occur if the mother is exposed to different stressful situations. The most common causes of premature delivery cited by participants were being young, carrying heavily loaded materials, accidents, family conflict , and severe illness during pregnancy. --- "As I am very young and I do not know the pregnancy. During that time gush of fluid passed, and I got to the hospital. After the assessment, the Doctor decided to do an operation after informed for me as the amniotic fluid drained completely. So, I perceived that the cause may be related to early pregnancy." . ". . .the causes for premature delivery are fall accidents and carrying heavily loaded material, as a pregnant mother cannot be allowed to grind coffee in a grinder or mortar. The government also not allow pregnant women to do heavy activities, as she did those activities it may cause premature delivery." . --- "As an experience, foreigners give special care if women become pregnant; they provide flowers, show feeling of love and give time to refresh their minds. Nevertheless, this is not apply in our community. When women become married and pregnant, they face different challenges such as the husband beating her, others my negligent and this may result in abortion and premature birth." . "The other cause for premature delivery is that, if the mother has malaria and cannot treated soon, the baby may be delivered premature or "shochetidi kees". After getting sick, if the mother is delayed to get health care, the baby is harmed." . "My baby was delivered at the seventh month, and during the seventh month of pregnancy, hypertension was diagnosed. Before that, I had anemia and this changed to hypertension. Due to that case, my fetus was unable to get healthy blood. After that, my baby delivered at the seventh month. . ." . --- Socio-cultural and spiritual factors. The community also perceived other causes of premature birth related to socio-cultural issues and spirituality. These causes are believed to be deep-rooted in the community and have existed for a long time as cultural and customary beliefs, such as "mich", "evil eye", and "ergiman". Some other participants also stated spiritually related causes, such as the will of God, "sin", "gome" or "lanche", witchcraft, and religious mentalities. There is also social pressure on pregnant mothers to do the same amount of strenuous activity as non-pregnant women. ". . .my wife was baking injera for others, and she informed that "mich" was one of the causes for premature birth for the first baby and this also true for the second baby even if she stopped the work before six months." . "The main cause for premature birth is "sin" or "gome" or "lanche" or if someone is not in God way or out of the will of God, and the activity or the circumstance disappointed the family member or someone else." . "Our community is also a perception problem if a pregnant mother avoid or is not willing to carry heavily loaded material and other activities, the community rumor that her pregnancy is unique, why she did not do that. Due to that case, the pregnant mother is enforced to do those activities and harm themselves and the concepts. Our community also perceived that "evil eye" can cause premature birth." . "Most people in our community perceived that the cause for premature birth is the will of God, "witchcraft" or "ergiman"." . --- Recognizing premature babies Physical features. The bodies of premature babies are immature, with soft and transparent skin that allows blood vessels and bones to be easily seen. They are also very weak and small. "I differentiate my baby as premature as it is very-weak, the skin is very soft, and the body is like blood as it is not mature and the body is transparent. We easily observe the bone and blood vessels of the baby." . "My baby was delivered in the seventh month, and it looks like "a rat that drown in water". If the baby is delivered in the ninth month the weight is 4 kg, but mine was a 1.8 kg female baby, and the Doctor gave a baby and informed this baby may or may not survive. When they put in the incubator, and the baby becomes unstable. After that, they assessed the health condition and the baby was well." . ". . .the baby looks like a little "chicken" . . . Until now, if we took the baby to health care institution, they told us the baby has malnutrition, and they asked "Does the mother not available for the baby?", and "Does the mother not feed the baby". After that, we told to them that the mother died, and the health professional become anger." . Limited range of motion. A few key informants and discussants stated that premature babies have a limited range of motion because their muscles and nerves are not fully developed. Premature babies cannot move their arms and legs freely in the incubator, and their bodies are limp and unresponsive. ". . .as premature babies are weak, immature, and the body is semis like a paralyzed person . . ." . Bizarre behaviors. Premature babies show some unusual characteristics compared to term babies. They are unstable and continuously cry for an unknown reason. When a breast nipple is placed in the baby's mouth, the baby does not show any signs of suckling. "Firstly, the baby continuously cries in the seventh month after delivery, and I do not know why the baby continuously cries. Nevertheless, the other individual has told me that the baby cries to indicate a need for a pacifier. They ordered me to provide a pacifier for the baby like a mother breastfeeding rather than wrapping by cloth." . ". . .the premature babies were unstable, continuously crying/shouting, and unable to suck due to discomfort in the abdomen, and I provide herbal medicine for the "evil eye". I also massage the abdomen of the baby for "bua" or hernia." . --- Community caring practices Warmth. The community provides warmth for premature babies in a variety of ways. After discharge from the healthcare institution, premature babies receive special attention in the community. They are immature and cannot withstand the external weather conditions as well as mature babies. They are dressed in cotton or cotton-wool clothes until they are several months old, skin-to-skin contact , sunlight exposure, swaddling, and wrapping with cloth. "The premature babies must put in cotton until eight or nine months to give warm and avoid cold." . ". . .I sited in a little chair, put the baby in my chest, and wore a coat to give warmth, and I stayed for 1-4 hours like a monkey. After getting warm for four-hour and the baby started a movement for searching breast to feed." . "I put the baby in the chest and hold it with a wrapped multiple cloths to make it hot until six months. Until six months, my baby does not go to sick, and the health status was well." . ". . .a premature baby exposed to sunlight after 15 days, as a mother warmth is not enough, but after 30 days for a term baby. Sunlight exposure is important for the baby to gain weight, and the baby exposed the sunlight every other day." . "My baby discharged early from the hospital as the weight is more than 2kg. So, the care given at home as the skin was very-weak and small. We prevent a baby from cold and moving air by swaddling and wrapping using a cloth made from cotton. We also carefully wash the body as the skin cannot strengthen that much, do not expose it for a long time, and avoid washing while setting in the direction of airflow." . Feeding. In the community, fresh cow milk and butter, formula, "muk" , and mother breastmilk were the most common feeding for premature babies. If the baby cannot suck the breast, the baby is fed using a pacifier. Some people may mix fresh cow's milk with boiled alcohol to kill germs. "My baby breastfeeds well, but it continuously vomits. Due to that case, I alternatively provide artificially prepared milk or formula "anchor" that I bought from supermarket. . ." . "The care given for premature babies is giving breast milk and fresh cow milk, and to prevent the child from germs as the baby consumes cow milk, we add boiled alcohol to the fresh milk given by bottle. As fresh cow milk is important to strengthen the body of premature babies and to grow faster. Health professionals recommended supplementary food for babies after six months. But, for premature babies, a "muk" made from barley cereal is also given to the baby in addition to fresh cow mild." . "I provided fresh butter at six months, and something like a black worm structure come-out from the anus, and we discussed with my mom that this was cause that the baby becomes to be very small. Because there was the woman who delivered at the seventh month with me, and her baby looks like a ninth-month baby." . Hygiene. Premature babies need frequent bathing and clothes changes to prevent infection and other complications, as their immune systems are immature. However, some study participants raised concerns that frequent bathing could expose premature babies to cold. To reduce the risk of infection, it is important to clean equipment, wash breasts before feeding, and use wipes rather than cloth or other materials after passing urine or stool. --- "The body of a premature baby must wash continuously to make it clean and comfortable." . "We bathed the baby every week to prevent cold while immersing frequently into the water as the body was immature. Again, after passing stool, we used a wipe to clean as washing with water or using other cloths are not much recommend for premature babies." . --- "I kept the hygiene by washing his body and changing the clean cloths frequently, and I washed my breast before giving it to him to suck, and all the equipment used for the baby must be clean." . Limit visiting. A few participants also reported that limiting the number of visitors is essential to prevent infection in premature babies. Premature babies are highly susceptible to infection because their immune systems are immature. This also helps to avoid discouraging new parents. "We limited the number of persons who visit the baby as informed by health care professionals to prevent infection and tease from other people." . Physical protection. Premature babies must be physically protected because they are very small and weak. The discussants and key informants stated that premature babies are easily harmed because their bodies are immature and soft. --- "I have not put my baby in the bed, as the baby was very-small and even it was difficult to differentiate the leg and the arm, and I am much suspicious as someone my sitting on the baby. As such, it needs critical care ." . --- Support for the mother with premature baby Family support. Premature babies need critical follow-up, and their mothers suffer more than others. As such, mothers who have given birth prematurely need support from their families . This support can include helping them with activities of daily living and participating in social affairs. --- "My husband support and allow me to do different household activities and to go social participations like "lekiso" or rituals, and other related social activities. After having those activities, I returned to the home, and my husband alternatively does those activities as caring for a premature newborn is very challenging." . "The support from the family is needed for the mother who faced such challenges like the husband, grandmother, grandfather and the mother-in-law, even neighbors must care for the baby and the mother must inform for those supports . . ." . Community or social support. The community must support mothers of premature babies during their care. A premature baby needs a caregiver who is fully present and attentive, and it is important for the mother to not have to leave the baby alone for even a few minutes. Because close follow-up of the baby limits the mother's ability to participate in society, the community should allow these mothers to take a break and provide psychological support. --- ". . .the neighbors and relatives may support the mother with a premature baby, and the local people and the kebele leaders understand the situation and give permission for the family until the baby strengthens him/herself." . "In our case, related to social life, the community understands that it is not mandatory until six months whether the baby is delivered term or prematurely. If the attendances called in "Idir" or "burial ceremony", and other activities, their neighbor informed them that she is "mechat" or mother of the baby." . Health professionals' support. All information about premature babies should be discussed during antenatal care, and the community must be aware of this through different mechanisms. Health professionals in the surrounding area also supported the mother with the premature baby by counseling on caring practices, such as feeding, bathing, maintaining warmth, and hygiene. Health professionals must provide information and mothers must be informed to avoid misconceptions in the community. "The health professionals in the health center gave counselling to the pregnant mother during antenatal care to avoid carrying heavily loaded materials, to have a balanced diet, and to keep herself from any situations that harm the mother as well as the fetus." . --- "The health extension workers also informed all the pregnant mothers and the husbands to avoid heavy loaded materials or equipment during pregnancy as it may harm the conceptus." . "My wife had a follow-up in the health center, and she got counseling service from health care providers regarding how to care for premature babies are given." . Government support. The government also plays a role in supporting mothers with premature babies by designing different strategies to raise community awareness and improve access to nearby health facilities and services. --- "As previously, the government provide "aja" for those mothers who are from low-income family and for premature babies also. The government also avail health extension workers at kebele level, and those provide different health-related information." . --- Challenges the women faced Difficult to feed. Almost all of the study participants stated that it is very challenging to feed premature babies. Premature babies are cannot suck and fully breastfeed. --- ". . .that premature babies do not suck, and it is challenging to feed them." . --- "I faced a great challenge in caring for my baby as it does not fully breastfeed and as most people said such like the baby does not grow, and it may die or pathway." . Difficult to bath. Bathing premature babies is challenging because their bodies are tiny and fragile. Some mothers panic when they see their premature babies for the first time. The skin of premature babies is easily bruised and very delicate, so it is important to be gentle when bathing them. --- "It is difficult to bathe the baby as the body is small and weak. Even, some mothers do not allow to unclothe and are frightened while seeing the body." . Limit social participation. Discussants and key informants explained that having a premature baby can restrict social participation. The mother may not feel comfortable leaving the baby at home with others or participating in community activities or social life. "My wife stayed at home to look for the baby, and she is limited for social issues. Nevertheless, I actively engaged in social activities like "Ikub", "Idir", "Yeho", and "Debo". As such, the neighbors know the situation, and they permit her to keep her baby." . ". . .it is difficult to grow premature babies as it needs close follow-up. It limits social interaction and other activities like going to the market, attending social ceremonies, and cooking food. The mother becomes hungry if someone is not around her as the baby continuously cries, and the mother does not cook food for him even after one month of delivery." . --- "I had not attended social graves or rituals, ceremonies, and festivities for long time, and the neighbors, the kebele administrates also understand the situation and they supported me." . Prone for infection or any disease. Premature babies have a less developed immune system, so they are more susceptible to infection than full-term babies. Vomiting and diarrhea are common symptoms of infection in premature babies. --- "It is very challenging that the baby faced diarrhea, vomiting, and tonsillitis. The baby is weak until now because he cannot get breast milk." . ". . .after discharging from the hospital, the babies developed wounds throughout the body, and the baby semis like a "pen". We challenged to manage and very stressed. My husband continuously prays to God that the baby becomes well. When we took the baby to the hospital, the health professional always asked why this baby is wasted as you are the mother of baby and you are well enough. Even if, I responded to them the baby was delivered in the seventh month, they cannot accept my response." . Psychosocial and economic impact. Delivering a premature baby in the seventh month can cause stress for families, who may find caring for the baby to be challenging and worry that the baby may not survive. Some people in the community believe that premature birth is caused by "sin" or "amilko", and that premature babies born in the eighth month will not survive. Caring for a premature baby can also have a negative financial impact on families, due to unexpected costs and the need to reduce working hours. "The baby delivered in the seventh month is challenging as the families are in trouble and stressed. The mother has faced a challenge if she gives birth to a premature baby." . --- "Growing a premature baby is challenging as psychosocially and economically affects the family. If a premature baby is born in the surrounding and the community perceive that this baby does not survive and always talks about that baby and this creates great stress on family members." . "We faced a challenge from the community that all are forwarded a comment that it is better if this baby was born in the seventh month as a baby born in the eighth month cannot survive. I believe an eighth-month baby is better than a seventh-month baby because the eighthmonth baby stays a month long in the mother's womb. Even, after being discharged from the hospital, most people believed this baby might die after two or three days. Nevertheless, the baby survived until now without any problem." . Lack of support from husband. The other main challenge for the mother of premature babies is the lack of support from her husband. "Mothers face the main challenge either during pregnancy or during caring for the child. The husband is simply as the name husband rather than sharing the burden of the wife." . --- Compulsory action Lack of hospitals in the surrounding. Premature babies need immediate access to advanced health services, but these services are often unavailable or inaccessible. This is a serious problem that needs to be addressed immediately. Pregnant mothers suffer greatly when their babies are premature, and the lack of access to advanced health services can make the situation even more difficult. "Pregnant mothers suffer more to rich to hospitals as there is no hospital in our surroundings, and mothers must go to the hospital via transport from the local health center if complications occur. We carry the pregnant mother via chair or bed to reach the main road to take to the hospital." . --- Lack of support from local health workers. As reported by the FGD discussants and key informants for IDI, support from community health workers or health extension workers is needed. They should closely follow premature babies after discharge from the hospital and create awareness of premature birth in the community. "After discharge from the hospital, as my brother is Doctor and he wrote all the information about my baby and informed me to give this written paper for HEWs in which the baby needs close follow-up. Nevertheless, they do not give support as my baby is unstable and seriously ill, even though they do not ask me about the situation. Due to that case, I consulted a traditional healer, he ordered traditional herbal medicine and informed me to re-visit again after two days, and he provided the medicine again. Then, the baby becomes stable without going to a healthcare institution. The herbal given to the baby was for "evil eye"." . ". . .said that the health extension workers in our surrounding do not follow the mothers who delivered in seven months. They also do not provide any information related to pre-term delivery rather than routine service like vaccination based on the ordered schedule and as provided in the campaign." . --- "Support from health workers is needed. Health professionals create awareness of premature babies through house-to-house visits, how those babies carried, does it grow or not. I feel that my baby lost due to my supplementation of fresh cow milk due to lack of knowledge on feeding premature babies." . Poor road construction and lack of transportation. The other focus area that the participants stated is poor road construction and lack of transportation to hospitals and clinics that provide qualified or advanced services. "The main challenge related to this is that it is difficult to rich the pregnant mother to the hospital, as the road is not well structured and we cannot access transportation." . --- Discussion Premature birth complications are a public health issue and the main contributor to neonatal mortality. Developed nations have seen a progressive decrease in neonatal mortality, but underdeveloped and developing nations have not. Despite different interventions, neonatal mortality has raised in Ethiopia. As such, it needs attention that premature birth increases from time to time. There are myths, misconceptions, and negative feelings about caring for premature babies in the community. A few studies were conducted in our country Ethiopia on premature babies. Nevertheless, there is a lack of evidence on perceived causes of premature birth, caring aspects, and challenges in the community. Therefore, this qualitative study aimed to fill those research gaps in the study setting. In this study, participants defined premature birth as the delivery before the ninth month of pregnancy. The perceived causes for premature birth were related to maternal, socio-cultural, and spiritual factors. The most common ways of recognizing premature babies were physical features, neuromuscular immaturity, and by their unusual characteristics. Almost all of the discussants and key informants reported that thermal protection for the baby was provided by putting in cotton and skin-to-skin contact, feeding cow milk, and "muk" in addition to the mother's breast milk. Mothers with premature babies frequently bathe them to keep them clean, limit visitors to prevent infection, and physically protect them. The community, family, health professionals, and the government should support mothers of premature babies. Mothers with premature babies face challenges related to feeding, bathing, and social participation. They also resulting in different costs as premature babies are prone to infection, psychosocial and economic impact, and lack support from their husband. The top prioritized compulsory action that the study participants stated was the lack of hospitals in the surrounding, lack of support from local health workers, poor road construction, and lack of transportation. In this finding, the majority of the participants stated that premature babies as babies delivered before completing the ninth month of pregnancy. However, a few participants challenged to differentiate premature newborns from low-birth-weight babies. This was also supported by the studies conducted in Malawi [1,16], Ghana [15], and Uganda [22]. This is likely because most laypersons relate prematurity with size and consider any baby with a very small birth weight to be premature. Therefore, it is important to raise awareness in the community about the difference between premature babies and low-weight babies. This can be done by community health workers. A study conducted in Malawi reported that the perceived causes of premature birth were categorized as maternal and general social factors. Maternal factors included not eating good-quality and enough food, doing excess household chores, being beaten by one's husband, frequent illnesses, having a previous abortion, having a family history of premature birth, and early or late childbearing. General social factors included the will of God, witchcraft, and the use of local medicine during pregnancy [16]. Similarly, a study conducted in Ghana speculated that teenage pregnancies, unsafe abortions, weak sperm of men, prolonged use of family planning methods, extramarital sex by the father, and witchcraft were perceived causes of premature birth. The beliefs about the causes of premature births were either mystical or natural phenomena. Beliefs about the mystical/supernatural causes mentioned were witchcraft, ancestral disagreements with the family due to disregard of what they require, powers of "wicked trees" and rocks within the surroundings, and very old animals, such as dogs and pigs, that live in the house [15]. A study from Uganda reported that biomedical-related explanations for the causes of premature births included diseases or other medical complications. However, many community members associated premature births with causes such as witchcraft from a co-wife, the will of God, and the occurrence of earthquakes [22]. Adolescents give birth to premature babies more often than adults, as indicated in a study done in Cameroon [23]. This finding also reported that being young, carrying heavily loaded materials, accidents, family conflict, and severe illness during pregnancy were identified as maternal factors during pregnancy that causes premature delivery. On the other hand, "mich", "evil eye", "ergiman", the will of God or "sin", "gome" or "lanche", and witchcraft were the perceived causes for prematureness related to socio-culture and spirituality. In this study, participants recognized premature babies by their physical features, neuromuscular maturity, and bizarre behaviors. Physical features they stated included soft skin, a transparent body , and being very weak and small. Limited range of motion was related to neuromuscular maturity. The most commonly stated bizarre characteristics were instability, continuous crying, and not showing signs of suckling. In line with this, studies conducted in Ghana, Uganda, and Malawi mentioned the following physical features of premature babies at birth: very small and transparent bodies that are soft, unable to suckle and breastfeed, absence of eyelashes, sunken forehead, many wrinkles, breathlessness, and floppy muscles [15,16,22]. This study found that the participants provided warmth for the premature babies by putting in cotton wool, skin-to-skin contact , sunlight exposure, swaddling, and wrapping with cloth. Different works of literature reported that warmth for premature newborns was universal care. It is provided by wrapping cloth, making fire inside the house, closing windows and doors, and keeping the baby inside the house all the time [3,16,18]. In contrast, most participants were little known and not practice skin-to-skin care and some practices were not appropriate that may harm the baby unless controlled, such as lighting lamps and charcoal stoves placed under the babies bed, and hot water jerry cans or plastic bottles put close to the baby [3,16,18,22]. There is also evidence that the mother should provide kangaroo mother care whenever possible, and if the mother is not available, fathers, partners, and other family members can also provide [18,24]. A study from Malawi found that expressing breast milk is a common practice for premature babies [16]. There is strong evidence that providing breast milk is the standard of care across all countries and the core of many national policies and programs for premature babies [24]. In contrast, this study found that the participants in the community provided fresh cow milk and butter, formula, "muk" and mother's breast milk using a pacifier. A few participants may have mixed fresh cow milk with boiled alcohol to kill germs. Similarly, a study from Uganda found that traditional birth attendants advised giving sugar water to premature babies if the mother perceived that she did not have enough breast milk [22]. This is malpractice, and it can harm premature babies and result in various complications. Therefore, it is best to avoid giving premature babies anything other than breast milk until they are six months old. Immediate and frequent bathing, changing clothes, cleaning equipment, washing breasts before feeding, and using wipes were the most common practices used by most of the study participants to keep premature babies hygienic. A few also reported bathing the baby after a week of delivery to prevent a cold. On the contrary, a study from Malawi reported that a premature newborn was not bathed until it reached nine months of corrected gestational age. A few kept the house clean by washing the newborn's clothes and sprinkling water on the house to control dust [16]. Another study indicated that the baby was bathed immediately after delivery and cooking oil was used on its body [22]. Almost all of the study participants in Malawi reported that premature newborns were not allowed to see other people until they reached nine months of corrected gestational age [16]. The main reasons they stated were the high susceptibility of premature babies to infection and constant dissuasion from other people. The discussants of this study also raised a similar idea. The mother, family, or anyone who provides care to the premature baby has a responsibility to physically protect or safeguard them from harm or injury even more than term babies. This point, stated by the discussants and key informants of this study, is that premature babies are very small and weak and can be easily harmed because their bodies are immature and soft. Community health workers advised mothers with premature babies on newborn care practices and promoted malaria prevention and family planning [22]. Similarly, home visits are recommended to support families in caring for their premature or low-birth-weight infants, as this can increase exclusive breastfeeding, immunization visits, and parental-infant attachment, and decrease parental stress and anxiety [24]. This study also reported that health professionals in the surrounding supported the mother with a premature baby by counseling on how the mother handles the baby . Families of premature or low-birth-weight infants should be given extra support and must involve in routine care. Those supports include education, counseling and discharge preparation by health workers, and peer support [24]. In the same way, the participants of this study also speculated that family, community or society, and government support are needed for mothers with premature babies. Mothers with premature babies faced challenges while providing care. These challenges included premature babies falling sick often, resulting in poverty, failure to do business and household chores, men starting sexual affairs outside marriage, and mother's lack of knowledge on how to properly care for them [16]. In line with this, study found that mother challenged to feed and bathe due to lack of knowledge, limits social participation, premature babies being prone to infection, psychosocial and economic impact, and women lack support from husbands. The compulsory action reported by the discussants and key informants were the lack of a hospital in the surroundings, lack of support from local health workers, poor road construction, and lack of transportation. The limitation of this study is that, due to its phenomenological nature, it may be affected by subjectivity and researcher-induced bias to some extent. Therefore, these factors must be considered when interpreting the findings of this study. This study highlighted a current public health issue and generated evidence that can be used to plan interventions. Policymakers and program planners can use these findings to design appropriate strategies for care practices for premature babies in the community. Deeply rooted practices in the community may put premature babies at further risk of complications. This study identified these practices and provided a roadmap for interventions and research. --- Conclusions The community has a gap in providing care for premature babies, and women with premature babies face challenges. There are malpractices in the community related to feeding and hygiene keeping for premature babies and the causes of prematurity. The challenges identified include difficulty and lack of knowledge on feeding and bathing premature babies, susceptibility of the babies to infection, psychosocial and economic impact, limiting social participation, and problems related to the husband. These findings are original and contribute to knowledge on this topic. Therefore, attention and awareness should be raised to avoid misconceptions about causes and caring practices, and there is a need to share the burden of women. --- All relevant data are within the paper and its Supporting Information files. ---

Premature birth is the leading cause of under-5 child mortality, accounting for 18%. More attention is needed for premature babies. Myths, misconceptions, and negative attitudes stigmatize premature births and slow prevention and care efforts. In Ethiopia, studies have been conducted on premature birth and its risk factors. However, there is a lack of evidence regarding the perceived causes of premature birth, caring aspects, and community challenges. This qualitative study aims to address these research gaps.This interpretive Husserlian phenomenological study was conducted from January 1-30, 2022. Purposive sampling was used to recruit 32 participants for focus group discussions and 10 participants for in-depth interviews. Participants included women, grandmothers, grandfathers, men, traditional birth attendants, and traditional healers. Interview and focus group data were analyzed using NVivo 12 Plus software and a thematic content analysis approach.In this study, the participants recognized premature babies by physical features such as transparent and bloody bodies, small and weak bodies, a limited range of motion, and bizarre behaviors. They perceived the causes of premature birth to be being young, carrying heavily loaded materials, accidents, illnesses, sin, social influence, and witchcraft. Participants provide warmth to premature babies by wearing cotton wool, making skin-to-skin contact, exposing to sunlight, and wrapping them in clothes. They also feed them boiled

Introduction Person-centered care is an important goal in long-term care organizations . Different studies have shown that PCC improves the well-being of both care recipients and caregivers [1,2]. PCC is central in the nursing home culture change movement to improve the well-being of long-term care recipients [2,3] and has been identified as a pillar of high-quality long-term care [4][5][6]. Although PCC has been defined in various ways [7,8], for this study, the key definition is that it encompasses connecting with care recipients "as unique individuals and recognizing that they have their own subjective experiences and preferences" [2] . There have been several studies on the organizational roots of PCC [9][10][11] and on identifying organizational determinants of PCC in nursing [2,11,12], but past research has primarily focused on specific and narrow measures of organizational processes, such as whether the organization provides access to electronic personal health records or whether there are clear PCC implementation plans [2]. There has been considerably less research on the organizational preconditions enabling PCC and even less research on these enabling and resilience-strengthening factors during times of environmental shocks such as the early periods of the COVID-19 pandemic. The aim of this study is to address this knowledge gap. The pandemic has challenged LTCOs to manage two problems simultaneously. To fight the pandemic, LTCOs have had to cope with pandemic-related issues such as implementing prevention rules, visiting bans, quarantine zones, test procedures, vaccinations, and use of protective equipment [13][14][15][16][17]. Those providing outpatient care have also faced difficulties such as maintaining hygiene standards and distance requirements under challenging circumstances [13,14,16]. Beyond pandemic-related issues, LTCOs have had to cope with the normal demands of daily routines, ensuring high-quality PCC. All of these challenges are aggravated when LTCOs also have to manage problems such as staff shortages, remuneration, and restructuring [18,19]. Additionally, there is a conflict between isolating care recipients to cope with the pandemic and prevent infections and providing PCC [20]. Under these complex conditions, some LTCOs have had difficulties in providing high-quality care during the pandemic, while others have not [21]. We argue that this variation is partly due to differences in the general capacity of LTCOs to act coherently as united and goal-oriented collectives. If LTCOs possess this general capacity to act collectively, they are better able to maintain routine tasks such as PCC despite having to cope with extraordinary burdens such as the pandemic. From an action theory perspective, LTCOs are organized collectivities that can adapt to the pandemic. To respond to both the normal and unusual demands during the pandemic, organized collectivities require a certain amount of systemic agency capacity. We define systemic agency capacity as the capability of a collective system such as an LTCO to fulfill four system-critical functions: adaptation , goal attainment , integration , and latent pattern maintenance . Within the structural-functional theory, these four functions are called AGIL functions [22,23]. They have to be performed to make a collective system ready to speak, act, and survive [23]. The adaptation function is fulfilled when a collective system is able to adapt to new situations because of given resourcefulness and because of flexible organizational structures and mindsets. The goal attainment function is fulfilled when a collective of people has the ability to define and set desired goals collectively, to monitor and control goal attainment, and to correct false goal-oriented strategies and actions [24,25]. The integration function is fulfilled when the parts of a collective system are closely connected through mutual trust, cohesiveness, and supportive networks [24][25][26][27]. The latent pattern maintenance function is achieved when the value and knowledge system as well as the belief system are maintained by institutionalization of value-based structures and are transferred to the next generation of members by socialization [23,28]. Systemic agency capacity can be understood as a higherorder function of these four AGIL functions that transforms a collective of people into a social system capable of shaping action; acting in the long term in an autonomous, self-organized, and autopoietic manner; and surviving its members. We argue that organizations with a high systemic agency capacity perform well on nearly all organizational performance dimensions because this capacity represents something similar to a general fitness of an organization that makes it generally ready to act in different situations and with regard to different tasks [29]. Resilience management [30] requires as a precondition an organization that is able to decide and act as an inseparable social unit. Thus, systemic agency capacity fosters resilience during crises such as COVID-19 by enabling LTCO to maintain routine tasks such as PCC under difficult conditions. Some studies support this view indirectly because they show that goal attainment and social integration are important for implementing PCC. For example, one study showed that goal-oriented leadership [11] facilitates the implementation of PCC. Another study demonstrated that hospitals that promote a culture of goal setting have been more suc-cessful in realizing PCC than hospitals without such a culture [10]. Additionally, a study by Stanhope et al. showed that transformational leadership, which incorporates having a vision and fostering a strong team climate among subordinates, facilitates the implementation of PCC [31]. In addition, some researchers have found that social cohesion in a health care organization is conducive to PCC [11]. Thus, our hypothesis is that the systemic agency capacity of LTCOs, which is measured by the AGIL scale, enables nursing homes to maintain and preserve high-quality routine tasks such as PCC in the presence of additional pandemic burdens. --- Materials and Methods We used cross-sectional data from an online survey of long-term care managers from outpatient and inpatient nursing and palliative care organizations in Germany surveyed in April 2020 and between December 2020 and January 2021 . --- Selection of Participants The contact information for the German facilities was obtained from a freely accessible data register on the internet. We contacted 4333 facilities by email, of which 3195 were registered as outpatient care services, 865 as inpatient care services, and 273 as hospices [32,33]. Only managers of a long-term care facility were eligible to participate in the survey. Other employees of a long-term care facility or managers of other facilities that do not provide long-term care were not allowed to participate in the survey. --- Measures We measured the systemic agency capacity of LTCOs using the AGIL scale, which is an additive scale standardized from 0 to 100 for analyses, with higher values indicating higher levels of systemic agency capacity. This scale is based on Parsons' AGIL concept [23], which states that social systems have to fulfill four functions to be able to act and survive. The AGIL scale was developed in previous studies [34,35] and specifically measures leaders' perceptions of the capacity of their organizations to easily adapt to different situations , install effective processes , set and strive for collective goals , be united and mutually trusting , and transfer knowledge and values to employees . The items of the scale have been previously used in a study on digital leadership [34,35]. The internal consistency and reliability of the scale is good . Table 1. Items of the AGIL scale surveyed among leaders of long-term care facilities in Germany during the COVID-19 pandemic. Thinking about your care facility in general, how strongly do you agree with the following statements? We are very capable of adapting to changes in our environment. In my area of responsibility, the business processes are highly effective. It is easy for us to define important targets. We pursue the defined targets with extraordinary persistence. In our care facility, there is unity and agreement. In our care facility, we trust one another. We have excellent knowledge management. We feel it is very important for new employees to internalize the values and attitudes of our care facility. PCC was measured using a scale consisting of ten items about the long-term care facilities' leaders' perceptions of the person-centeredness of the facility they lead. The scale includes three different elements of person-centeredness: the degree of shared decision making, care recipient participation, and orientation toward client preferences . Parts of the scale were developed and cognitively pretested in a previous study of health care organizations [36]. The scale has been adapted to the context of LTCOs. Internal consistency of the scale is good . An additive score of the PCC items was created and standardized on a scale from 0 to 100 for the analyses, with higher values indicating greater levels of person-centeredness. The type of LTCO and the survey cycle were included as control variables. Thinking about your care facility, how strongly do you agree with the following statements currently ? The care recipients are asked about their preferences regarding care. The care provider and the care recipient jointly weigh the different care alternatives. The care provider and the care recipient decide together which care will be provided. The preferences of the care recipient are identified and explicitly taken into account during care. Regular checks are made to see if care recipients still have questions. The care recipient's preferences regarding care are documented. The care recipients receive company, support, stimulation, advice, encouragement and assistance in the process of change/adaptation. The reference persons of care recipients receive support, guidance, advice, encouragement and assistance in the care situation. At our care facility, we always adhere to standards and guidelines . 10 At our care facility, the care recipient's relatives are involved in the care upon request of the care recipient. --- Statistical Analysis We performed descriptive analyses and multivariate pooled cross-sectional regression analyses using Stata V.16.0, and the multivariate analyses tested whether agency capacity as measured by the AGIL scale, the survey cycle, interaction of these variables, and the type of facility predicted perceived PCC [37]. Within the regression analyses, we tested whether the beta coefficient of an independent variable is significantly different from zero. The beta coefficient predicts the degree of change in the outcome variable for every 1-unit of change in the independent variable. --- Results For the first survey cycle of 4333 eligible managers, 765 participated in the survey, of whom 503 fully and 207 partly completed the survey, and 25 did not agree to be interviewed. For the second survey cycle of 4185 eligible managers, 520 participated in the survey, of whom 294 fully and 192 partly completed the survey, and 29 did not agree to be interviewed. The analytical sample consisted of 503 managers in the first survey cycle and 294 managers in the second survey cycle after the exclusion of cases with missing information . The analysis of the type of organization indicated that both surveys were comparable with regard to the types of organizations that participated . The perceived PCC score increased significantly between the outbreak of the pandemic and the second wave from 74 points during the first wave to 79 points during the second. Similarly, the mean scores on the AGIL scale increased significantly between the two survey cycles from 73 to 77 . The multivariate regression analysis that included all variables simultaneously in model 1 showed that the AGIL score was significantly associated with the PCC score . A 1% increase in agency capacity measured on the AGIL scale was associated with a 0.5% increase on the PCC scale score . The survey cycle had a significant effect, indicating that institutional person-centeredness increased from the first pandemic wave to the second pandemic wave . The nonsignificant interaction term in model 2 between the survey cycle and the AGIL scale indicates that the association between perceived agency capacity and perceived PPC did not vary significantly by survey cycle . Accordingly, as shown in Figure 2, predicted margins of PCC increased with higher levels of AGIL but did not differ significantly between the two survey cycles. The introduction of organization type as a control variable showed that hospice, outpatient nursing care, and outpatient care facilities provided significantly higher PCC than inpatient care organizations , with the largest difference found between hospices and inpatient care organizations. The analysis of the type of organization indicated that both surveys were comparable with regard to the types of organizations that participated . The perceived PCC score increased significantly between the outbreak of the pandemic and the second wave from 74 points during the first wave to 79 points during the second. Similarly, the mean scores on the AGIL scale increased significantly between the two survey cycles from 73 to 77 . The multivariate regression analysis that included all variables simultaneously in model 1 showed that the AGIL score was significantly associated with the PCC score . A 1% increase in agency capacity measured on the AGIL scale was associated with a 0.5% increase on the PCC scale score . The survey cycle had a significant effect, indicating that institutional person-centeredness increased from the first pandemic wave to the second pandemic wave . The nonsignificant interaction term in model 2 between the survey cycle and the AGIL scale --- Discussion The main objective of this study was to test the hypothesis that the ability and power of LTCO to act flexibly, sustainably, and in a goal-oriented manner as a cohesive collective system, called systemic agency capacity, is a precondition for the ability to maintain highquality routine tasks such as PCC during the COVID-19 pandemic. The regression results showed a significant association between perceived systemic agency capacity as measured by the AGIL scale and perceived PCC during the COVID-19 pandemic. This association did not differ between the first and second survey cycles, indicating that the 0 10 20 30 --- Discussion The main objective of this study was to test the hypothesis that the ability and power of LTCO to act flexibly, sustainably, and in a goal-oriented manner as a cohesive collective system, called systemic agency capacity, is a precondition for the ability to maintain highquality routine tasks such as PCC during the COVID-19 pandemic. The regression results showed a significant association between perceived systemic agency capacity as measured by the AGIL scale and perceived PCC during the COVID-19 pandemic. This association did not differ between the first and second survey cycles, indicating that the association was quite stable over nine months. This significant association could be interpreted as preliminary proof for the hypothesis that the systemic agency capacity of nursing homes enables the provision of high-quality routine care during a pandemic. However, this is not a proof of causality but rather suggests that we could explore this hypothesis further. The results of this long-term care facility study are in line with the results of two other organizational studies [24,25,27]. These studies showed that hospitals that fulfill two of the four AGIL functions-goal orientation and integration-have higher implementation rates with regard to quality management or clinical risk management than hospitals that do not fulfill these two functions properly. As mentioned above, these two components are part of the systemic agency capacity construct. Additionally, there are some empirical hints in the literature regarding the importance of organizational properties such as social cohesion and goal-oriented leadership for the promotion of PCC [10, 11,31] that support our hypotheses and the result of this study. In addition, there are studies showing that in the context of the COVID-19 pandemic, social support-an important subdimension of social integration-is a useful resource for health care workers in coping with traumatic stress [38]. Social support was found to be related to stress resilience during the pandemic [39]. In times of the COVID-19 pandemic, social support can play an important role in maintaining the health of health care workers [40], for example, as a protective factor [41]. This is an important prerequisite for long-term care workers to provide high-quality care during a pandemic. Despite the supporting literature, these results should be interpreted with caution. One cannot exclude the possibility of a selection bias caused by the repeated cross-sectional design, which produced different participation rates in the survey cycles, and time constraints of top managers of nursing care facilities during the first and second waves of the pandemic. Leaders who felt more affected by the pandemic might have been more motivated to participate, which could have led to a selection bias. Although the study involved LTCOs throughout Germany, the results may not be representative of all LTCOs in Germany. For reasons of anonymization, the present study was not a panel study. In future studies, researchers should attempt to overcome data protection issues and design a panel study. Future studies could also include specific resilience resources such as pandemic-specific budgets to study their interaction with the general resilience resource agency capacity. Future studies might also consider measuring PCC from the patients' perspective to counteract common method bias. --- Conclusions LTCOs have had to face two challenges during the COVID-19 pandemic: coping with the pandemic and ensuring high-quality routine tasks such as PCC. We hypothesized that high systemic agency capacity as measured by the AGIL scale is a general core resource that enables long-term care facilities to maintain routine tasks such as delivering PCC despite the disruption caused by the COVID-19 pandemic. Our study provided some empirical support for this hypothesis. Owing to the constraints of this study, especially the repeated cross-sectional study design, these results are only preliminary. Despite these limitations, the results highlight the need for nursing leaders to focus attention on the social infrastructure for crisis management [29]. Maintaining the basic functions of an organization is a crucial but often neglected central task of nursing leaders. The main strategy should be to foster the systemic agency capacity of LTCOs by strengthening the central components of this agency capacity. Therefore, nursing leaders should implement structures and processes that enable adaptability and efficacy through adequate tools [42]; enable a common goal setting by consensus workshops and goal attainment by controlling the goal attainment progress with appropriate dashboards and controlling tools [25]; enable solidarity by stressing the importance of "we" and developing a climate of supportive and cohesive relationships; and enable knowledge and value transfer by establishing appropriate measures such as mentoring systems, onboarding events, or standard operation procedures [43][44][45][46]. --- Data Availability Statement: The data presented in this study are available on request from the corresponding author. --- Informed Consent Statement: Informed consent was obtained from all subjects involved in the study. ---

Is the Systemic Agency Capacity of Long-Term Care Organizations Enabling Person-Centered Care during the COVID-19 Pandemic? A

Introduction In the current market conditions -growth of production, expansion of the market offer as well as in the face of civilisation and cultural changes -the issue of consumer behaviour is gaining particular importance, both in theoretical and practical aspects. The consumer, as an important market participant, is increasingly actively participating in the process of purchasing and consuming goods and services. His behaviour is becoming more complex and characterised by great variability. Due to the dynamic civilizational and cultural development, consumer behaviour has for many years been the focus of interest in many sciences such as economics, management, sociology, psychology and security. As a result of the changing economic, social and cultural conditions of consumption, new trends in social consumption behaviour arise and are understood as a specific direction of changes in the preferences of market participants, which is a consequence of changes taking place permanently in the market environment . The diversity of these preferences is the effect of external factors originating directly from the environment, i.e., the existing value system, prevailing customs, traditional forms of behaviour, and the mechanisms and institutions governing the contemporary economy. Each individual's decision is also based on their individual characteristics . Also, special circumstances in the environment such as a pandemic can also significantly modify or change many of them. The aim of this research paper is to attempt to analyse the relevant economic and social factors influencing consumer behaviour in a situation caused by the SARS-CoV-2 virus. --- Factors Influencing Consumption Behaviour -Systemisation Consumer behaviour is most often defined as the process of selecting, buying, using, accepting or rejecting products, ideas or experiences in order to satisfy an individual or group's needs or desires . More broadly, they encompass the mental and physical activities, including their motives and causes, performed by individuals and groups in the cycle of consumption for the pursuit of their goals and values, resulting in satisfaction and well-being, taking into account the individual and social effects of these attitudes . Consumption and consumer behaviour are determined by a number of consumer-dependent factors and environmental variables. Internal factors include: disposable income, occupational activity, wealth and savings held, current level and structure of consumption, etc. External determinants are formed by the socio-economic situation of the country and the influence of the international environment, the globalisation of economies and the use of information and communication technologies . A very different view of internal and external factors can also be found in the literature. Internal factors can include : needs and desires, attitudes and preferences, personality, learning , risks associated with buying. The last of these seems to be the least appreciated. Purchase decision risk occurs when the buyer is undecided and perceives the danger of making the wrong decision. Customer purchase decisions can be associated with the following types of risk : functional risk , physical risk , economic risk . External conditions that determine consumer behaviour include: economic, social and cultural factors; marketing and non-marketing incentives -the environment. According to the researchers in this field, the economic factors themselves can be divided into three groups: macroeconomic, microeconomic and demographic. Macroeconomic factors relate to the further economic environment, which is not directly influenced by the consumer. They create the conditions to which the consumer adapts and makes purchasing decisions within the framework of these conditions. This group includes the supply of goods, the availability of which, and therefore the ability to make choices, is an important tool in shaping consumption . Factors that are not directly dependent on the consumer include the price of a given product, the characteristics and quality of the product, and the advertising activity carried out by entrepreneurs. The basic microeconomic factors, on the other hand, are the level of income of the consumer responsible for the satisfaction of needs. Other concepts are directly related to the category of income: expenditure, savings, possessions. Economic factors can be regarded as fundamental because they determine the consumer's possibilities . The last group of demographic factors includes those describing the consumer and the household . The age of the consumer is important when analysing behaviour, as needs, expenditure and consumption change along with it . Consumer income is the most important economic factor. It is the means by which needs are satisfied, it influences consumer spending and the level and structure of consumption. Variation of consumer behaviour are caused by changes in the level and structure of income. Its increase leads to an increase in demand and, conversely, a decrease leads to a decrease in demand. Social factors influencing consumer behaviour are, first and foremost, roles and social status along with reference groups. By consuming products of certain brands, using certain services or making purchases in certain places and circumstances, consumers accentuate their social status as well as their membership in certain groups. Activities related to the process of purchasing and consuming goods and services thus acquire a social dimension and in many situations are accompanied by the satisfaction of needs such as establishing interpersonal contacts or spending leisure time with family and friends . This group also includes cultural factors, which essentially determine the consumption patterns of society members, namely their culture, i.e., the totality of their spiritual and material heritage, customs, beliefs and patterns of behaviour . The occurring cultural changes are significantly influencing the evolution of values, attitudes, motivations and perceptions of modern consumers. Traditional values such as family, cultivated customs and a willingness to make sacrifices are increasingly being put on an equal footing with new values such as individualism, self-fulfilment, material comfort or health . Consumption is also subject to globalisation processes, linked to the homogeneity of purchasers' needs and the consequent homogenisation of consumption patterns, which are spreading across borders and creating a global consumer culture . The described factors determine consumer behaviour, which ultimately leads to purchase. The purchasing process is the totality of activities related to the purchase of products and services, together with the decisions preceding and conditioning these activities. It usually consists of five phases: awareness of need, search for information, evaluation of alternatives, purchase decision, purchase, post-purchase feelings . The role of consumers in shaping the market is crucial regardless of the situation, whether it is relatively stable economically or accompanied by a crisis. It therefore becomes particularly important to know the total factors influencing consumer behaviour and to adapt them to the prevailing environment. --- Pandemic and Selected Determinants of Market Behaviour The crisis caused by the pandemic and its accompanying effects have had a decisive impact on consumer behaviour and market participation processes. No matter what factors caused the crisis, whether typically economic, political, natural or biological disasters causing pandemics, the sense of security of society is threatened in many dimensions: economic, psychological, social. The new, unknown situation causes uncertainty and fear for existence. The crisis is associated, among other things, with an increase in the indebtedness of the economy, rising unemployment and a decline in demand and investment levels. In addition to the economic effects, it should also be considered in the social dimension, as it affects the sphere of social life, e.g., by worsening the mood of the population aware of the collapse of the economy . The Congressional Research Service report of 04.05.2020 states that the pandemic has hit individual economies through many channels. It has stunted or completely stopped production and consumption, disrupted supply chains and disrupted trade flows. It has effectively upset many markets, including oil, and shaken stock markets. It has led to increased unemployment, inactivity, extreme poverty and even food shortages. It has threatened not only the solvency of some companies, but also the governments of many countries . Researchers from Harvard Business School in Boston, distinguished four customer segments during the crisis : ▪ Slam-on-the-brakes segment -"those who hit the brakes hard", least resistant to the crisis, reducing their needs and expenditures, looking for opportunities and substitute goods. ▪ Pained-but-patient-pragmatic, more optimistic than consumers in the first segment, but nevertheless distanced and focused on saving. They represent the largest group of consumers. In the event of a deepening crisis, they migrate to the first segment. ▪ Comfortably well-off -"financially secure", optimistic about their future, the recession has not significantly affected their consumer behaviour. ▪ Live-for-today consumers-"living today", not guided by in-depth analysis of the economic reality, not changing their habits, postponing important purchases, not saving. This segment is mainly represented by young people who are unstable in their professional and private lives. As a result of the coronavirus pandemic, people at households have found themselves in a unique, unusual situation. Family, work or social life has changed, although probably to different degrees for individual members of society. It should be noted that consumer behaviour has showed significant differences in the different phases of the pandemic Borsellino et al. with his cooperators synthesised research on the impact of the coronavirus pandemic on food purchasing behaviour. In the initial period, increased shopping and stockpiling caused by fear and uncertainty were characteristic of most consumers. Once accustomed to the situation, purchasing habits became highly differentiated and determined by attitudes towards COVID-19, personal experiences, economic status and much more. In parallel with the pandemic, there was an increased interest in home cooking, buying from local suppliers, buying food online, as well as acquiring healthy food and reducing wastage . The KPMG report shows that a group of economic factors has decisively influenced consumer behaviour. The research found that for 44% of respondents, the financial situation has worsened or significantly worsened. For these consumers, the purchasing process has become more complex, as purchasing decisions have become more deliberate. 75% of Poles declared that the outbreak of the pandemic affected their spending habits, while half of respondents admitted to holding back on non-essential spending as a result of COVID-19 1 . Reports from other countries affected by the pandemic also confirm the importance of these factors. The research conducted by EIT Food in 10 European countries, proved that the financial situation of many shoppers worldwide has worsened. In the survey, as many as 55% of respondents claimed they were short of money at the end of the month and 34% of those surveyed had lost some or all of their income. As a result, ⅓ of the respondents admitted that price is the decisive criterion for them when it comes to food purchases2 . Further confirmation of the relevance of price levels, as well as the need to buy, is the PwC report. The research confirmed that consumers significantly reduced their spending on non-food purchases . In addition, the PwC report showed that in a pandemic situation, consumer behaviour was highly variable, with the only constants being buyers' expectations of low price and value of goods and services purchased 3 . Research firm McKinsey & Company has outlined changes in consumer behaviour since the start of the pandemic. Significantly lower household incomes in both Europe and the US have translated into a reduction in the quantity and quality of purchases, as well as the postponement of purchases. The consumer, fearing that their financial situation will deteriorate, may reduce the propensity to consume and increase the propensity to save, in order to secure future consumption. Nationwide Polish research has shown that, regardless of inflation, the high price of high-quality food is the main barrier limiting the growth of food demand, particularly among low-income consumers. The higher the income of consumers, the higher the proportion of people consuming more fruit and vegetables and protein-rich products. Households with the lowest incomes saw an increase in the consumption of high-energy foods . Professors at the Cracow University of Economics, Żbikowska, A and Chlipała, P. provided interesting conclusions regarding attitudes determined by socio-economic and factors. A large group of consumers were more likely to postpone purchases as a result of the pandemic. At the same time, a similar proportion of respondents bought goods or services for altruistic motives, to support producers or sellers. Other pro-social behaviour of consumers did not change significantly. Postponing purchases is also strongly related to fear of a pandemic -people who are more afraid of the disease are more likely to give up purchases by postponing them until the future. It is noteworthy that a significant proportion of respondents indulged in reflection on the problem of over-consumption of goods in the wake of the coronavirus. One in two respondents declared that, after the pandemic had ended, they would purchase fewer products than before . Consumer behaviour is therefore becoming more considered and rational, and decisions to purchase products are made from the perspective of the utility that the good being consumed can provide. Having limited resources at one's disposal in an economic crisis, and seeking to maximise satisfaction, leads to a rationalisation of consumer behaviour. The dilemma faced by the consumer is the allocation of money between different purposes. The decisions that the consumer will make in this regard according to G. Cato's theory of consumer behaviour are characterised by greater conservatism and prudence. In times of crisis, these characteristics seem to be particularly evident, especially when these decisions are taken over a longer time horizon and are so serious that they require a more in-depth analysis of possible consequences, as well as an assessment of the consumer's current and future financial situation . Of the social factors, attention should be paid to the educational level of the society. Firstly, an increase in educational attainment increases employment opportunities and influences wage levels and income growth. Secondly, an increase in the level of education is correlated with an increase in health awareness, which influences the openness of society to new consumption trends and changes in the structure and quality of purchased goods, including food . --- Conclusion It follows from the above considerations that the pandemic has had a significant impact on the behaviour of market participants, often forcing consumers not only to change their lifestyles, but also to change their habits, routines and patterns in the area of purchasing and using consumer goods or services. Considering the aforementioned economic factors, in the current era of market events, it is necessary to emphasise the role of inflation, which is synonymous with a widespread increase in the prices of goods and services over an extended period of time, combined with a decrease in the value of money . The material situation, income, job security of the population is one of the most important economic factors influencing the demand for food goods and services. These factors shape the size of purchasing power, in turn, its differentiation in the socio-professional cross-section influences the structure and level of consumption among particular groups of the population. Rising prices of food, energy and fuel prices have forced changes in consumer behaviour, leading to spending restraint and more frugal living. General conclusions: ▪ economic and social factors have decisively affected consumer behaviour; ▪ the pandemic situation caused a deterioration in the financial situation of most households, which affected the saving process; ▪ the Covid 19 pandemic caused spending to be limited to what was necessary and influenced a reduction in the quantity and quality of purchases, as well as postponing them; ▪ consumer behaviour became more thoughtful and rational and decisions to purchase products were made from the perspective of the utility that the consumed good could give; ▪ members of society with higher education and social status found it easier to find their way in the new situation and had greater awareness and knowledge, in case of job loss it was easier for them to find a new job. The pandemic situation, which has been followed by various socio-economic transformations taking place both in the consumer environment and within households, has led researchers to take an interest in consumer behaviour, changes in their preferences or the structure of consumption alone. --- Credit Authorship Contribution Statement The article was written solely by me with no input from others. --- Conflict of Interest Statement As the author of the article: I declare that the research was conducted in the absence of any commercial or financial relationship that could be construed as a potential conflict of interest.

The outbreak of the COVID-19 pandemic marked the beginning of huge changes both in the economy and in the attitudes of purchasers in many market sectors. The dynamically changing reality and uncertainty about the future resulted in a variety of consumer reactions such as: refraining from purchasing certain goods and services and postponing spending. The impact of the pandemic can be considered in the context of factors shaping consumer behaviour: economic, e.g., level and sources of income, supply, price level and relations, as well as noneconomic. This article addresses the issue of consumer behaviour during a pandemic and attempts to analyse the economic and social factors influencing purchasing decisions. The article is theoretical in nature, but includes a review of various Polish and foreign studies conducted during that period. The purpose of the publication is to determine to what extent the pandemic condition caused by COVID-19 changed the behaviour of Polish consumers taking into account economic and social factors. In particular, how did the pandemic restrictions affect purchasing behaviour, expenditure structure, savings and final decisions made by consumers. A research gap in this area has been identified.

Introduction For more than a decade, the problem of mental health in children, with rates of those affected being between 10% and 20%, worldwide, has increased [1,2]. We know that new generations are now more likely to have mental health problems than previous ones, and that inadequate mental health may be linked with suicide cases, which are the second and third causes of teenage mortality, according to several international studies reviewed [3]. If, at the same time, we take into account that 50% of adults' disorders had their onset in adolescence, it seems necessary to perform an analysis of the factors that affect the mental health of minors, not only as a treatment measure, but also with the aim of preventing future disorders [4,5]. In fact, the presence of mental health problems in the parents could be a predictor of mental health problems in children, and therefore this situation would form a cycle where the difficulties could pass from parents to children [6]. Two main difficulties for this analysis are the use of different questionnaires that make difficult to compare the international samples studied, as well as the fact that local studies do not allow the generalization of the results. To overcome these obstacles, the Strengths and Difficulties Questionnaire -parents version [5,7]-has been implemented in this study. This questionnaire has been used with a Spanish population previously [6,8,9], and has demonstrated good qualities for measuring mental health at a national and international level, especially with its scoring at the total scale in difficulties [7,10]. In the present study, we use the same scale as was included in the Spanish National Health Survey [8,11]. This questionnaire, in its 'parents' version, has proved to be a good tool for the screening of mental disorders in cross-cultural studies in European countries, establishing itself as an international mental health measurement tool [12]. Several reports indicate the need to analyze which variables affect the mental health of minors, and encourage the social sciences to collect data in order to clarify the increase of mental health problems in minors in Western countries [2,10,[13][14][15]. According to previous analyses with Spanish national samples, it seems that the occupational class of parents could be a relevant variable for the mental health of minors [16], with less favored classes predicting worse results in the mental health of minors. As in North America, those with low-income parents associated with low occupational classes had higher levels of depression and anxiety [17], and may even experience feelings of helplessness and inferiority, or behaviors of alcohol abuse [18]. Given the economic crisis in Spain since 2008, it seems necessary to analyze the variables that may affect the mental health of Spanish minors. Therefore, the objective of this study is to analyze the influence of variables such as "occupational class of the parents", "educational level", "sex" and "perceived health"-according to the 2011 Spanish National Health Survey-on the mental health of Spanish children aged between 4 and 14 years old. --- Materials and Methods --- --- Instrument The instrument used was the SDQ-parent questionnaire [7]. It has been translated into 66 languages and internationally validated [9,19,20]. It is an instrument of excellent quality for the screening of mental health in minors, and its usability, as well as the reliability of the scores, makes it very attractive for research [21,22]. It consists of 5 scales of 5 items each. The total score for difficulties is calculated based on the sum of the first 4 scales , avoiding the sum of the last scale , as has been established in the methodology of previous research using the SDQ, including that of Goodman and Goodman, its creators [22]. To facilitate the analysis of mental health, once the answers had been obtained, the score of each minor-that would vary between 0 and 40 points-was divided into two categories: suffering or not suffering from mental health problems, based on whether the total score was greater than or equal to 20 points or less than 20 points [9,23]. This variable was contrasted with the complementary sociodemographic information obtained through interview: occupational class, educational level, sex, and perceived health. Six occupational social classes were considered, based on the Spanish adaptation of the British Registrar General classification [24]. The authors grouped them into three social classes for better study: class 1 , class 2 and class 3 . Additionally, based on the minors' age, three corresponding educational levels were considered: Pre-School Education , Primary Education and Compulsory Secondary Education . For the perceived health in the last year, three levels were considered: "good or very good", "regular", and "bad or very bad". --- Procedure The type of sampling used was stratified tri-stage. The information corresponding to the questionnaire for minors was obtained indirectly, facilitated in our case by the mother or the father. The method of collecting information was Computer-Assisted Personal Interviews , direct in the case of adults, and the mother/father or guardian. This is to say that, in our study, we have only selected those responses by parents of the minors. This survey was approved by the Committee of Good Practices of the European Statistical System under the protocol of action of the National Institute of Statistics and Ministry of Health Social Services and Equality developed by ENSE-2011 . --- Analyitic Approach Analysis of variance techniques were used to analyze whether there were significant differences between the total score obtained in the SDQ-parent test and the independent variables or selected factors, such as sex, educational level, occupational class, and perceived health. In order to analyze the association between having or mental health problems or not with respect to the risk factors mentioned above, we used the statistical tools of odds ratio and relative risks . In this last analysis, we used the occupational social class 3 and Compulsory Secondary Education as comparative control classes. For the regression analysis, 189 subjects with missing or incomplete observations were eliminated. The remaining subjects in the sample were all included. --- Results In Table 1, the frequency distribution and percentages of the mean of the scores reached in the SDQ test, 'parent version', can be observed, according to the risk factors chosen. A priori, there appear to be significant differences in means in the sex factor, the educational level factor, the occupational class factor and among the three categories of the perceived health factor . Through the analysis of a general univariate linear model, the sex factor and the educational level factor show significant differences . Scheffé's post hoc tests show that these significant differences exist between Pre-School Education and all other categories , and there are no significant differences between the categories Primary Education and Secondary Education. In addition to this, minors who are in Pre-School Education have a higher propensity to suffer mental health problems. As far as the occupational class is concerned, there were significant differences between the means of their categories and there were significant differences among the three occupational level classes in Scheffé's post hoc tests. Finally, in relation to perceived health in the last year, significant differences were obtained between the means of perceived health levels . Furthermore, through Scheffé's post hoc tests, different means were obtained in the three levels, with minors who presented poor or very bad perceived health during the last year being the most likely to have mental health problems. The results given in Table 2 present the measurements of the linear relationships between the total score obtained in the test and the risk factors . Risk factors explain 5.5% of the variability of the total score of the SDQ, but the influence of all of them is very significant, together and separately . On the other hand, taking into account the risk factors arises the interest in calculating the odds ratios and relative risks of being ill or healthy . --- Discussion and Conclusions According to the results obtained in this study, it seems that, although the sex, the age associated with the corresponding educational level, the perception of health in the last year, and the occupational class are factors that affect the total score in mental health difficulties , it is exclusively the health over the last year and the occupational class that have the capacity to influence the distinction, at a diagnostic or screening level, between sick and healthy. Regarding sex, boys are more likely to have higher overall mental health scores than younger women. However, these differences disappear when we use the cut-off points of healthy and sick for the Spanish population. They may have worse symptomatology, but at the time of either diagnosis or more thorough screening, it seems that there are no significant differences, as this agrees with the data obtained in the ENSE-2006 [9,25]. Although it is not the goal of this paper, other studies have shown that, when analyzing pathologies not globally, but in terms of scale, there is a greater symptomatology of behavioral disorders and externalizing symptoms in boys at an early age, and a more frequent occurrence of symptoms of eating disorders, depression and internalizing symptoms in girls as they progress toward adolescence [13,26,27]. On the other hand, if the child's educational level is taken into account, minors in the Pre-School stage are at higher risk of having mental health problems than those in primary education or secondary education, with primary education having a higher risk than Secondary Education. These results are in agreement with other studies that involved measurements of total SDQ scores of children between 6 and 18 years old, and where the highest scores were in the lowest ages [16]. Even so, the scientific literature is quite divergent with respect to the effects of age on the mental health of the minors or, in this case, of age associated with academic level [26]. However, when we analyzed the ability of this factor to discriminate between healthy or sick, which had not been carried out by previous investigations in Spain with this sample, no differences based on the educational level of the child could be observed. These results are in agreement with those obtained in the Spanish National Health Survey 2006, previous to the one analyzed here [28]. At the same time, factors such as "low parental education" may be a factor that negatively affects children's mental health, especially in the early stages , without affecting later stages at adolescence [29]. Some authors [30,31] point to socioeconomic status and parental education [32] as the most common causes of mental health problems in minors. This study shows the existence of an association between parents' lower occupational class and an increased probability of suffering mental health problems in minors. The most qualified occupational class offers a factor of protection in comparison to the unqualified working class, which is in agreement, again, with the data of the ENSE-2006 [16]. Other studies confirm the influence of parents' low occupational class on the mental health of the children in the Spanish and international population [29,33], even specifying how behavioral disorders or problems of hyperactivity, emotional problems, and peer problems increase in children that belong to these families [28,34]. It seems that occupational class and, even more, the presence of unemployment, both associated with low income, may be factors that favor the appearance of mental health problems in Spanish minors [28], having the capacity to to enhance depression in adolescent girls and alcohol abuse behaviors in boys [18,35]. At the same time, there is a positive relationship between the occupational class and quality of life, with this factor having an impact on the promotion of health problems, not only mental, but also physical [34]. In this sense, the significant differences of this study show how poor health in the last year favors the possibility of suffering mental health problems. Health perceived as good or very good is a protective factor against the occurrence of mental health problems, and this remained the same in both health surveys, 2006 and 2011 [9]. These results also coincide with other recent research that advocates the association between good mental health and good physical health [4]. This could indicate the need to analyze mental health when the child complains of a poor physical health in the last year, which would imply the relevance of primary care in health centers for the detection of mental health problems. At the same time, it seems that a poor socioeconomic situation, associated with a low occupational class, may influence not only poor mental health, but also poor physical health and lifestyle [15,36]. It therefore appears that socioeconomic status, associated with the occupational class of the parents, can influence mental health and, in turn, the physical health of minors [36,37]. Although differences in mental health problems have not been perceived in minors before and after the Spanish economic crisis [38], it does seem important to highlight how occupational class remains a determinant factor for their mental health in both periods. In fact, a low socioeconomic status is related to major mental health problems in parents and, as a result, to mental health problems in minors [9,30]. It is important to emphasize that, despite the strength of this study in carrying out a national population analysis under a rigorous methodology, it would be advisable to resolve its limitations through the use of the SDQ questionnaire together with clinical interviews offering information complementary to that obtained from the use of the questionnaire. Thanks to the results of this study, it can be concluded that the low occupational class of the parents [39], connected with the poor health of the child in the last year [25], may be risk factors for Mental Health Problems in minors. Although there was a decrease in the psychological and emotional problems of Spanish children between 2006 and 2012 [1,2], it is noteworthy that these factors remained relevant to the Spanish population, whether before or during the economic crisis . Therefore, social policies are needed for detecting those families with these variables in order to be able to work with this population and to prevent future pathologies in mental health [2]. --- Author Contributions: F.F. is the principal investigator, and wrote the manuscript. I.R. and E.S. synthesized the literature, and made the translation and adaptation. F.F., E.F. and B.L. analyzed the data and contributed to discussion. ---

Research on minors' mental health is an increasingly developing area. Given the increased prevalence of disorders, it seems necessary to analyze the factors that can affect poor mental health. This study analyzes the influence of occupational class, educational level, age, sex and perceived mental health of Spanish children, which is measured through the Strengths and Difficulties Questionnaire. The sample consists of 3599 minors between 4 and 14 years old, who were interviewed through the Spanish National Health Survey 2011. Our results indicating the significant (p < 0.05) relationship between mental health, occupational class (OR 0.533) and minors' health in the last year (OR 0.313) are shown. However, gender (OR 1.187) and educational level of Pre-School Education in relation to Secondary Education (OR 1.174) and Primary Education (OR 0.996) do not generate significant differences. In conclusion, we consider it necessary to design and implement public policies aimed at improving the care system for children who have had poor or regular health in the last year, and whose parents are positioned in the lowest part of the occupational scale.

A. Introduction Marriage is part of the legal instruments prescribed by Islam. This marriage law binds the relationship between men and women who are not mahram, which gives rise to rights and obligations between the two. Marriage is also a form of realization of God's promise to make women wives of the male type , so that compatibility and perfect humanity can be realized. He also creates a sense of mawaddah and ar-rahmah between the two of them so that they help each other complete their lives. The essence of marriage is not only an external bond but also an inner bond between husband and wife in a household life that is harmonious, peaceful, and fostered with love by the will of Allah SWT. It is not only worldly-oriented but also spiritual, making it a sacred matter that must be accounted for morally and spiritually. The realization of this is that Islam regulates marriage issues in a very detailed and thorough manner. Islam sets the conditions and pillars of marriage. In fact, not only, Islam also provides instructions and guidance starting from the pre-wedding process, starting from selecting a partner, the process leading up to marriage, to its implementation. All of this is carried out by adhering to the noble values of Islam. This is not only a form of manifestation of the urgency and nobility of the institution of marriage, but also to ensure the realization of the goals of marriage. Therefore, this is where formal legal certainty is important to ensure the realization of the goals of a marriage. In this case, the institution of marriage has an important role in forming relationships whose existence is recognized. However, in subsequent developments, the institution of marriage is faced with various challenges that could threaten its existence. Namely when faced with social problems that can disturb the sanctity of the institution of marriage. One of them is the emergence of the problem of pregnancies that occur outside of marriage. This problem becomes increasingly complicated when in today's social life it turns out that cases like this often occur in society. The various factors behind the marriage of pregnant women due to adultery in Bandung Regency reflect the social problems within it. Problems of education, quality of family and environment as well as understanding of traditions which are reduced by the development of society are things that need to be considered regarding the incidence of marriages of women who become pregnant due to adultery. These realities include the marriage of pregnant women due to adultery which occurs in the Bandung Regency area with various causal factors. This problem is not only related to the number of cases of pregnant marriages due to adultery that occurs, but from a sociological aspect, this is of concern because there is still a repetition of the same cases without maximum mitigation efforts. The repetition of cases of marriage of pregnant women due to adultery is even accompanied by a culturally permissive attitude. This attitude is reflected in the case of marriages of women who become pregnant due to adultery, most of which are celebrated as normal marriages so that the impression of discomfort, shame, or disgrace becomes an excuse. Distortion of understanding related to the marriage of pregnant women due to adultery has become a social fact that represents contradictory societal perceptions regarding efforts to overcome the problem of marrying women pregnant due to adultery. The marriage of pregnant women due to adultery as part of a legal issue has become a discourse among fiqh scholars so on this issue there are various views. As Syafi'i allowed and considered his marriage to be valid. Abu Hanifah also thinks so but adds the requirement that a pregnant woman can be married but cannot have sex before she gives birth. Meanwhile, the opposite opinion was given by Maliki and Ahmad Ibn Hambal who forbade the implementation of this marriage The perception of formal law that does not touch on the existence of elements of deviation from norms in the issue of the marriage of pregnant women due to adultery as part of a social problem has implications for the weak functioning of the law in terms of social control. Law as an existing instrument in people's lives will ultimately reflect the degradation of moral values and a paradigm shift in a society that is influenced by the permissiveness of legal instruments and the need for dynamization of legal provisions in realizing their objectives by the problems, conditions, and needs of society. Likewise, the socio-cultural perception that exists in society should be able to play a role in preventing and dealing with cases of pregnant women marrying because of adultery. Socio-cultural forces that have existed long before legal formalization with moral values, religious norms, and various patterns of social interaction are important aspects that can play a role in social control, including in the field of marriage law. However, the reality represents a shift in values regarding this matter. Apathy or low levels of social awareness, individualism, discomfort, and permissiveness in society have implications for the lack of efforts to address the issue of marriage incidents involving women becoming pregnant due to adultery. This is also indicated by the public's perception of understanding and awareness of the law regarding the marriage of pregnant women due to adultery which does not indicate that the issue of this marriage event is a worrying social problem. This is a study that needs to be carried out because the problem of marriage incidents involving pregnant women due to adultery has legal and sociological implications which also influence the social structure in the context of the realization of legal order. --- B. Research Methods This research is descriptive qualitative, namely by describing the application of legal regulation in the context of its implementation in society to explain it systematically, factually, and accurately. According to Soerjono, and Soekanto., descriptive research is also intended to confirm hypotheses, so that it can help strengthen old theories or develop new theories. --- Data Source This research is included in the field research category so the type of data used is primary data in the form of findings or facts obtained from the field. The data source in this research is the people of Bandung Regency, represented by sources who have relevance to the marriage problem of women who become pregnant due to adultery. The data sources in this case are the perpetrators of pregnant marriages due to adultery, the parents of the perpetrators of pregnant marriages, employees of the religious affairs office, religious leaders, community leaders, and local government officials. --- Data Collection Techniques Data collection techniques are an important element in research. Therefore, the use of data collection techniques is closely related to the relevance of the type and objectives of the research. In this research, the following data collection techniques were used: a. Observation This observation technique is a data collection technique carried out through direct observation of the research object. This observation was carried out on the social or socio-cultural patterns that exist in Bandung Regency, the paradigm and attitudes of society towards the widespread marriage of pregnant women due to adultery, social behavior such as social patterns, the role of parents in child development, the social cohesion of families experiencing this problem, as well as various actions from elements of society and the state as well as activities of social organizations, both formal and informal, which represent a form of response to the marriage of pregnant women due to adultery. b. An interview is a conversation with a specific purpose carried out by two parties, namely the interviewer who asks questions and the interviewee who provides answers to those questions. With interviews, it is hoped that researchers will obtain more in-depth information about the topic being researched, which cannot be found through observation. c. Documentation is a technique for searching for data in the form of notes, transcripts, books, newspapers, magazines, inscriptions, agenda meeting minutes, and so on, both as a source of study, explanation, and strengthening of data obtained from the field. Documentation in this research includes collecting data or information through written materials, whether from statutory regulations, books, archives, as well as field notes, or the results of interviews and photographs during the research. --- C. Results and Discussion --- Objective Conditions of Marriage for Pregnant Women Due to Adultery in Bandung Regency Cases of repeated marriages of pregnant women due to adultery indicate that there are social problems that have not been or are not being handled properly. The social problem that is the cause of cases of pregnant women marrying due to adultery is an issue that is closely related to the implications and efforts to overcome this kind of marriage problem. For the people of Bandung Regency, the issue of marrying pregnant women due to adultery is not a new and extraordinary problem. Most people view the marriage of pregnant women because adultery is a common thing. This is not only influenced by society's lack of comprehensive understanding of the law regarding the marriage of pregnant women due to adultery, but it is also due to the culture that has developed in social life and the large number of cases of pregnant marriages that occur. There are various indicators commonly used by society to determine that a marriage is the marriage of a woman who is pregnant due to adultery. Among these indicators are the following: a. There is a rush to a wedding. Javanese wedding customs, with all their elements, require preparation for the bride and groom's family. It is not only a matter of material things but for the Javanese people, marriage as an important event in the stages of human life must be taken into account when determining the day of the contract . b. Changes in a woman's physical condition Marriages of pregnant women due to adultery that occur in teenagers can be indicated by the physical changes in question. The public can find out about this at the wedding reception or when interacting with the person concerned. Physical changes in young women indicate the physical appearance of someone pregnant or pregnant. c. Birth distance from the marriage contract. The gestational age that is commonly understood both in terms of general public understanding and medical parameters is the basis for the normal gestational age, which is approximately nine months and ten days. In other words, if the distance between the marriage contract and the birth is less than the normal gestational age or the distance between the birth and the contract is only a few months apart from the baby's physical appearance at a normal gestational age, then this is strong evidence that the marriage that occurred was a pregnant marriage. d. Information that is developing in the Bandung Regency community which still has good sociological ties, generally social interaction takes place quite closely between members of the community. This is not only proven through the practice of social life with the values of cooperation which are still often found in various community activities, but the closeness of this interaction can also be seen from the fact that community members have known each other for quite long distance, not only between RWs. --- Factors that cause pregnant women to marry due to adultery in Bandung Regency Marriage is an event that is considered important both from a religious and sociological perspective. The urgency of marriage is then manifested in various efforts and expressions, traditions, and regulations related to marriage. This urgency also cannot be separated from the function of marriage. Functions that do not only concern individual or individual issues but also the functioning of marriage in the context of social life. In general, the factors that cause the occurrence of marriages of pregnant women due to adultery in Bandung Regency can be divided into two, namely: a. Internal Factors The internal factors in question are factors that exist in the subject or perpetrator. In several cases of marriages where women become pregnant due to adultery, several internal factors cause the marriage to occur. These factors are: Low awareness of education. In several cases of marriage, pregnant women due to adultery occurred to perpetrators who were still nine years of compulsory school age or perpetrators whose educational level did not reach high school level. In other words, teenagers with such an educational history are very vulnerable to experiencing this kind of marriage. Lack of religious awareness. The lack of formal education among the perpetrators and the neglect of religious education certainly greatly influence the basis of a person's behavior. Adolescence, with its various problems and psychological immaturity, makes it very possible to fall into negative things such as promiscuity . b. External Factors The external factors in question are related to external influences on the perpetrator, in this case, it can be viewed from two factors, namely: Family Factors The family, as the smallest unit of society, is a place that plays a very important role in the formation of a person's character. Interaction between individuals is certainly a factor that inevitably causes incidents of marriage between women who become pregnant due to adultery. Environmental Factors The development of a person's personality cannot be separated from their environment. These environmental factors also play a role in the marriage of women who become pregnant due to adultery. --- Implications of the Marriage Event of a Pregnant Woman Due to Adultery in the Socio-Cultural Perspective of Bandung Regency Society The marriage of a pregnant woman due to adultery is a marriage that is preceded by an act that contains an element of violation of norms, whether religious norms or moral norms, and even under certain conditions it can also be considered a form of legal violation. This preliminary act is a form of sexual intercourse carried out outside of legal ties, which in religious terminology is called zina. The act of adultery as a form of violation in the provisions of Islamic law has legal consequences in the form of quite severe sanctions, including being beaten up to stoning. Such sanctions certainly sociologically have implications for society's perspective towards the perpetrator. This kind of action is not only considered a violation of social norms but also a violation of legal norms because it has elements of disturbing public order Regarding the legal impact of the marriage of a pregnant woman due to adultery, according to the fiqhiyah rule "Whoever hastens something before the time, then he bears the consequences of not getting that something." The existence of a pregnant marriage is a loss of rights that should be obtained for the perpetrator, namely the loss of the birthright of the child conceived to its biological father. This is the legal implication that is directly accepted by those involved in marriage who become pregnant due to adultery The incidents of marriages of pregnant women due to adultery in -Bandung Regency are not recorded in quantity in official documents from any party either at the KUA or in the sub-district -. However, it cannot be denied, or is even no longer a public secret that cases of such marriages are something that happens a lot. Formal legal provisions clearly and unequivocally provide that pregnant marriages are valid and there is no need for remarriage after the unborn baby is born, as stipulated in article 53 KHI paragraph . Therefore, for KUA officers, procedurally there is no standard examination regarding this matter. Even if there are direct or indirect indications that the marriage case of a pregnant woman due to adultery was discovered during registration at the KUA. These indications include the presence of an element of urgency or suddenness in the marriage registration process. Information about cases of marriages of pregnant women due to adultery is also obtained from confessions from people who register marriages, who are generally religious figures or heads of RT and RW who are asked to help take care of the things needed for the marriage process. The discussion related to the issue of marrying pregnant women due to adultery in this case is not limited to the quantity of cases that occur, but also to the various implications, both related to legal and social issues. The reality of cases of marriages of pregnant women due to adultery which occur repeatedly or continue to occur in Bandung Regency shows that this marriage problem has an impact on the life of the community. These implications are as follows: a. The marriage of a pregnant woman due to adultery is an obstacle in efforts to foster Islamic law in society -Bandung Regency. Community development is part of the state's obligation to its citizens. However, it should not be understood that this obligation is only the domain of the state or government, the development of the people is also a collective obligation, including the obligation of every family. Community development certainly cannot be separated from the law as the controller and guarantor of public order. Community conduciveness is an important element in creating a prosperous society. b. The issue of marriage of pregnant women due to adultery that occurs, degrades cultural values and traditions that have lived and developed in society -Bandung Regency. Marriage from the cultural perspective of Javanese society is a very important phase because the main meaning of the marriage ceremony is the formation of a new family. Apart from this meaning, marriage is also interpreted as a way to expand ties of brotherhood. c. There is a shift in society's paradigm regarding the issue of marriage to women who become pregnant due to adultery. Cases of repeated marriages of pregnant women due to adultery without serious attention from society indicate the socio-cultural perspective of society towards pregnant marriages as something commonplace. The reality that there are cases that are related to the subject or perpetrator either by kinship, proximity of domicile , or social interaction correlation, in several cases of marriage of pregnant women due to adultery shows that the domino effect in these cases occurs because of the presence of role models in a case. with new cases emerging. d. The marriage of pregnant women due to adultery is a social problem and reality that is counterproductive to improving the quality of human resources. A pregnant marriage with a background that is termed the result of an "accident" provides a picture of an unintentional event. Therefore, the mental and material readiness of the parties, especially the bride and groom, is certainly an important issue that has a direct impact on the formation of the household. Likewise, from a family perspective, a marriage resulting from an "accident" certainly causes problems, especially psychologically. --- Bandung Regency Community Perceptions of the Legal Provisions for Marriage for Pregnant Women Due to Adultery The law of marrying a pregnant woman due to adultery from a fiqh perspective has different views among the jurists. The implication of this is that the understanding of law in society varies. Therefore, in a formal legal manner, the state as the holder of legal authority in Indonesia adopted a policy through the provisions of the Compilation of Islamic Law, article 53 concerning the permissibility of marrying a woman who is pregnant due to adultery with a man who impregnated her without having to carry out a remarriage after the baby she is carrying. was born. This provision, apart from referring to the views of Shafi'i jurisprudence, also aims to guarantee the protection of the rights of children in the womb. Apart from this, sociologically, the permissibility of pregnant marriage is a form of rehabilitation for perpetrators of pregnant marriages due to adultery so that they can socialize with society with the status and spirit of self-improvement through the marriage. This perception of legal reasoning is interesting if it is related to religious knowledge that is understood by the majority of society. Recognition and practice of religious communities with the Syafi'i school of thought believe more in carrying out remarriages. And this is what many people in Bandung Regency do in responding to the marriage of pregnant women due to adultery. Viewed from a legal sociological point of view, as stated by the head of the KUA -Bandung Regency, the marriage event of a pregnant woman due to adultery should not be carried out until the birth of the pregnancy. This is a form of sanction so it becomes a lesson for others. However, legally there is no prohibition on marriage and the KUA cannot refuse to marry in cases like this as long as the legal requirements are met. A practice that often occurs in society is marrying off a partner in the marriage of a pregnant woman because zina is cirri and after giving birth they are officially married off to the KUA. This is done in cases of pregnancies that are considered old enough or there are other reasons that the family believes should not be officially married first. This reason is like the woman's parental blessing which has not been fully given to the man who impregnated her child so the marriage is just a fulfillment of religious issues. This reality shows that society's perception of the marriage of pregnant women due to adultery empirically takes into account recommendations from religious figures rather than making decisions based on state regulations. The public's legal understanding and awareness of formal provisions like this shows that the effectiveness of existing laws is considered to be less representative of the needs and conditions of society. Understanding the law of marriage for women who become pregnant due to adultery cannot be separated from the formal provisions of article 100 KHI which confirms that children born outside of marriage only have a lineage relationship with their mother and her mother's family. In this regard, the dictum of article 100 of the KHI is in letter law contradictory to the provisions of Islamic law relating to the determination of this nasal. The contradiction in this case lies in the editorial use of "child born out of wedlock" whereas in the provisions of Islamic law, a child who is assigned to his mother is a child born from sexual intercourse outside of wedlock. --- Efforts to prevent the marriage of pregnant women due to adultery in Bandung Regency The discussion is related to efforts to overcome the problem of pregnant marriages because adultery cannot be separated from society's paradigm towards this kind of marriage. The societal paradigm that explains the marriage of a pregnant woman due to adultery, both from the family concerned and society in general, shows that such marriages are not a serious problem. Therefore, in reality, cases of marriage of pregnant women due to adultery still occur in the community -Bandung Regency. However, there is a paradigmatic announcement by society regarding the marriage of a pregnant woman due to adultery, normatively, in this marriage, there are aspects that conflict with both religious norms and social norms. So there are countermeasures from various elements of society, namely as follows: a. Preventive Efforts Preventive means preventing something from happening. Preventive measures; namely actions taken before a social deviation occurs so that an act of violation can be suppressed or prevented. Preventive control is generally carried out through guidance, direction, and invitation. b. Curative efforts or actions are efforts that can help cure diseases and so on and have the power to treat them. Curative action; This action is taken after an act of social deviation occurs. This action is aimed at providing awareness to perpetrators of deviation so that they can realize their mistakes and be willing and able to improve their lives so that in the future they will no longer repeat their mistakes. c. Repressive Efforts Repressive efforts are efforts that are to suppress, restrain, or restrain. Repressive action is an active action taken by related parties when social deviation occurs so that the deviation that is occurring can be dealt with. Such efforts in the matter of marriage are carried out through raids or catching "red-handed" perpetrators of adultery as actions that cause the marriage. This is generally carried out by the authorities or elements of society such as the Community Police Partnership Forum together with local civil service officials. --- D. Conclusion and Suggestions --- Conclusion The marriage of a pregnant woman due to adultery is a legal issue as well as a social issue. Based on research on the reality of marriages of pregnant women due to adultery that occurred in Bandung Regency, the following can be concluded: a. The perception of the people of Bandung Regency towards legal provisions regarding the marriage of pregnant women due to adultery is greatly influenced by the function of social institutions through religious figures and community leaders, this has implications for the effectiveness and understanding of the community toward formal laws regarding the issue of pregnant marriage. b. The marriage of pregnant women due to adultery which occurred in Bandung Regency was a social reality that was considered normal and then constructed the sociological paradigm of society -Bandung Regency which empirically describes the society's permissiveness towards cases of women pregnant due to adultery. c. Efforts to overcome the problem of pregnant women marrying due to adultery have been carried out by various parties in Bandung Regency. These efforts include preventive, curative, and repressive efforts. However, existing efforts are still pragmatic and incidental. --- Suggestions Based on the results of the discussion and conclusions, recommendations can be made in the form of suggestions, including the following: a. Legal certainty which is transformed into statutory regulations is not intended as a restraint on legal functions which are tied to textual aspects. Therefore, for related parties, stakeholders, and stakeholders to prioritize the conditions and needs of society by using alternative legal sources extracted from local wisdom, consensus rooted in tradition which can be used as a legal approach to deal with incidents of pregnant women's marriages because of adultery that occurred. b. The prediction of a Regency City as an educational city with all regional regulations such as the implementation of study hours and curfews must be strictly implemented down to the RT-RT. These positive policies will be more effective if they can collaborate with existing elements of society such as majlis ta'lim, Karang Taruna, or community protectors as government partners to control these policies. c. The cooperative attitude of the people of Bandung Regency is an important asset in dealing with the marriage of pregnant women because adultery continues to emerge. Every element in society should be aware that this issue is a social problem that must receive serious attention. This awareness must be manifested in a system that is not only incidental. In short, to address and overcome cases of women becoming pregnant due to adultery in Bandung Regency, goodwill from all parties is required. Ta 'lim, Vol. 15, no. 1

This research wants to explore the law, factors and causes, implications, public perception, and efforts to overcome pregnancy in marriage due to adultery. This research method is a qualitative descriptive approach. Data collection techniques through a. Observation at the research location. In-depth interviews with informants. Documentation of existing data such as meeting notes, books, and archives related to research. The conclusion is that the impact of cases of pregnant marriages due to adultery which occur repeatedly has shown that there is a form of announcement that reflects a shift in the socio-cultural perception of society regarding the issue of marriages of pregnant women due to adultery. This reality is contradictory in the context of social law. Efforts to address the problem of pregnant marriages have been carried out by existing social institutions that do not represent comprehensive and systematic efforts. Therefore, reconstruct the societal paradigm regarding the issue of marriage, and pregnancy due to adultery. To resolve problems that must receive attention from various parties.

INTRODUCTION Chronic Obstructive Pulmonary Disease is a major cause of morbidity, mortality and health-care costs worldwide . At early grades, COPD is characterised by cough, sputum production and breathlessness associated with persistent airflow obstruction. As the disease progresses, exacerbations and comorbidities severely affect patients' quality of life . The gradual disability often leads to dependence on family, who become central to assist with activities of daily living, manage complex treatment technologies, monitor breathlessness, provide emotional support, participate in decision-making and facilitate communication with health care providers . Caring for a patient with moderate-to-severe COPD can be a burdensome experience , associated with poor quality of life , poor self-rated mental health , and high levels anxiety/depression symptomatology . Sleep problems, restrictions in social and professional life, and financial strain have also been reported by COPD carers . While these studies provide valuable knowledge on the COPD caregiving experience, they have been conducted with samples composed almost entirely by women, keeping the men's reactions overlooked. However, the caregiving role may be experienced differently in men and women. To the best of our knowledge, there are no studies focusing on men´s caregiving experience in COPD. --- Men's caregiving research With the demographic changes occurring in most of Western societies, an increasing number of men have been involved in caregiving roles . Nevertheless, as caring for an ill family member has traditionally been described as a women's activity, a significant body of the caregiving literature has focused on women's experience. Research have supported gender differences in caregiving, with women more likely to engage in personal care, perform a wider range of tasks , and reporting higher levels of burden and depressive symptoms than men. These suggest that men "weather" the caregiving process better . Some would argue that men are more able to keep emotional distance from their caregiving role or to rely more on problem solving coping strategies than women , whereas others would suggest that men are motivated by love and women act out of duty . Nonetheless, most studies use men as a contrast group to show the additional challenges faced by women, thereby overlooking the unique experience of men as carers and hiding within-groups variation . Kramer , however, has found high rates of depressive symptoms among husbands caring for wives with dementia and high psychological distress among older husband caregivers over time has also been reported . Studies comparing men carers with men non-carers found greater symptoms of depression, lower levels of marital satisfaction and poorer quality of life for the former . The few existing qualitative studies also suggest that men carers experience personal conflict, loss, guilt and loneliness . Yet, the caregiving roles differ for husbands and sons: while husbands tend to see it as an extension of their marital role, in sickness and in health, , sons seem to perceive caregiving as a reversal of the parent-child role . A number of researchers have proposed examining men carers as a group in and of themselves . Still, these studies are limited in number, focusing mainly on husbands and centred on chronic conditions such as dementia or cancer . As different chronic conditions present distinct caregiving demands , research needs to demarcate each disease's specificities from the general aspects of caregiving . Therefore, this study aimed to explore the experience of husbands and sons providing care to a family member with moderateto-severe COPD. --- METHOD --- Study design An exploratory qualitative study was conducted with twelve men carers, recruited from two primary health care centers. The study received full approval from the Institutional Ethics Committees. Men carers were included if they were: ≥ 18 years old; husbands or sons of a person with COPD; the primary carer ; able to understand the purpose of the study and agreed to voluntarily participate. Clinicians from the health care institutions were asked to identify and classify outpatients with moderate-to-severe COPD , who were cared by men carers. Eligible outpatients were contacted by telephone by a clinician's assistant, who informed about the study and asked their willingness to be contacted by the researchers. Interested participants received a telephone call from researches, were informed about the study specific objectives and were asked to identify their primary carer. A total of 16 men carers were identified and invited to participate. All agreed to participate and a meeting was scheduled in the primary health care center. Four carers failed the meeting due to health deterioration of the cared-for person, and a final sample of seven husbands and five sons was composed. Written informant consents were obtained prior to any data collection. --- Data Collection Socio-demographic data and information on the caregiving situation were collected through a structured questionnaire. In-depth, semi-structured individual interviews were conducted. Interview questions were informed by extensive review of research on general family caregiving, COPD caregiving and men's caregiving. Specifically, participants were asked about: the meanings ascribed to the caregiving role ; the impacts and challenges ; fears and concerns ; and positive aspects . The interviews were conducted by a gerontologist with experience in COPD research and qualitative interviewing, but without personal experience with COPD diagnosis. On average, interviews lasted 50±5 minutes. All interviews were digitally audio-recorded with participants' permission for further transcription and analysis. --- Data Analysis The interviews were transcribed verbatim. The transcripts were analysed using thematic analysis . Carers' identification was coded and fictitious names were used to preserve anonymity. In the first step of the analysis, one interview transcript was read repeatedly and in depth by the researchers. Interpretative notes were made and the emerging subthemes were grouped together into major themes. After this process, the themes and subthemes were listed and connections were looked for between researchers. No substantial differences were found. In a second step, the other transcripts were read to look for new themes/subthemes and confirmation of the themes/subthemes already encountered. After independent analysis, the researchers compared and discussed the findings to reach a consensus. Consensus was obtained based on the richness and importance of the theme/subtheme in the transcripts. To assure credibility the peer debriefing technique was performed . This technique consisted in a review of the methodology procedures and data by a third researcher independent to the study, who challenged the researchers' assumptions and asked questions about method and interpretations. To ensure the reflexivity, the research team held regular group meetings to reflect and discuss issues related to the study . --- --- < Insert Table 1 about here > Both husbands and sons identified the type of care provided. Husbands were more likely to perform household work, emotional support and medical appointments accompaniment when compared with sons . Only one carer, a son, received formal support, particularly from home care services. --- < Insert Figure 1 about here > --- FINDINGS Although common themes have emerged, analysis revealed different subthemes regarding the sons or husbands' caregiving experience . Participants' perspectives are presented with representative statements. --- < Insert Table 2 about here > --- Husbands' perspective Caregiving as an extension of the marital role. The experience of providing care to wives was perceived as part of the husband's role, contributing to a sense of continuity in the marital relationship. All husbands maintained the usual dedication and attention in everyday life: "I have always given the best support when she needed. Nothing has changed, our relationship is exactly the same" [August]; "I don't see much difference. I have adapted to the situation." [Albert] However, caring for wives also meant a constant concern. Two husbands expressed the importance of a commitment to wives' care, especially due to the unpredictability nature of COPD exacerbations and hospitalizations: "I have always paid attention to my wife, but now I pay even more. She tries not to show her frailty… She thinks she has to do everything. But I'm always there and I do whatever it takes" [Ernest] To protect and help their wives, husbands felt they should be proactive and adapt to the new demands of COPD: "When I was employed I couldn't give that support, now [that I can] I had to learn how to do it." [Anthony]; "I became more concerned with her. When she's coughing, she's fragile, and therefore she must eat well. She tries to resist but I take care of her." [Ernest] Providing household tasks. All husbands were actively learning to adjust to COPD demands. Performing new daily tasks that used to be undertaken by their wives, such as planning meals, cooking, cleaning and laundry, was a challenge. "There are things I can do, but I'm a man. I don't know much about cooking. The soup cannot fail, but the most difficult is to cook other things. I have no difficulties with the laundry but I don't know how to iron. But everything ends up being done." [Albert]; "The housework is the most difficult. I've worked away from home and my wife did everything. Starting to learn is hard for me, I have to cook and I have to ask her how. I really need more help at home." [Paul] The cooperation within the couple facilitates the adjustment to family roles' changes. Husbands' difficulties in performing housework were attenuated by wives' orientations: "I do the shopping and the daily cooking but with her orientations. Usually she's lying down resting and I ask her how it's done. I learnt things that I have never done in my whole life." [August] Preserving wives' integrity. Three husbands seek to preserve the dignity and self-esteem of their wives. They engage their wives as active participants in care and day-to-day decisions. However, some of them were afraid that wives' self-confidence and self-efficacy could gradually decrease due to the worsening of the symptoms and deterioration of their health condition: "The concern is always on my mind because she was always a fighter, always worked, she couldn't be stopped. I'm afraid when she starts to lose her strength. She has difficulties doing her tasks and that worries me a lot. I am afraid that she starts feeling bad about it" [August] Losing the life partner. All husbands reported the fear of losing their life partner. This fear was mainly related to the uncertainty and unpredictability of COPD symptoms: "I feel that she has to stop and sit on a chair, to rest a bit, to receive oxygen and then start again, but after an extra activity she needs to sit again.This worries me a lot." [August] Husbands were afraid of their wives having a painful death due to asphyxia. "Death! I am afraid that my wife will suffocate… we do not have the means to protect from happening, we must immediately go to hospital." [Albert]; "I'm afraid of losing her suddenly." [James] Fears of losing a major source of support were raised when husbands anticipated the loss of their spouses, as they felt emotionally dependent on them. "I'm afraid that COPD will get worse and I am a person who depends a lot on her. I always say I want to die first. It is my wish because I know she has a lot of strength and courage to face it. I do not have it." [Ernest]; "If one day she's not there for me, I won't have any chance." [Anthony] Practical skills to manage COPD and adequate treatment. All husbands felt they should improve their ability to care. Specifically, they expressed the need to respond appropriately to worsening of symptoms . Husbands wished to learn how to manage exacerbations, e.g., to help their wives when they were short of breath."I have no knowledge. If I´ll need to take her to the hospital, I will. But dealing with the specific medication [bronchodilators] is more difficult. She knows what to do, I don't." [Ernest]; "A sudden complication or worsening symptoms, how can I help? I'd really like to know, to be informed. I am interested to learn all about her illness." [August] Given the lack of information and limited access to adequate health services, husbands claimed an appropriate treatment for their wives, which could lead to improvements in their respiratory symptoms and quality of life: "She needs an adequate clinical management of her disease. She really needs specialised care so that the disease does not get worse." [Anthony]; "She needs someone, a person to help and take care of her. We've been looking everywhere for good --- specialists." [Paul] Wives' self-confidence and emotional strength. All husbands recognised their wives' selfconfidence and strength as positive aspects of caring. Given the difficulties and constraints of being a men carer, wives's support and positive attitude towards the disease strengthened their caregiving role: "The disease never brings anything good, but if I can point something positive about this situation, is seeing how strong she is… [emotional crying] If it was not her courage and inner strength the situation would be much worse. Sometimes she is the one who gives me courage and hope…" [August]; "She has the same vitality and strength that she had 10 years ago. She never runs out of energy. For a woman with her age and with a respiratory problem, she really does a lot [Laughs]" [Albert]; "Even with such a hard health condition, she is very strong" [Louis]. Additionally, the presence of a nurturing relationship and emotional commitment was referred as a strength in the care relationship: "The positive part is her companionship, she's very important to me. She gives me the support I need; she's very strong, stronger than me. She helps me a lot, --- emotionally. She's very positive in all situations, she's an excellent partner… " [Ernest] --- Sons' perspective Fulfilling a sense of duty. All sons stated that their sense of duty to care for their ill parent led them to assume the caregiving role. The care receivers' restrictions caused by COPD and the unpredictability nature of the symptoms led sons to care for their parents. A son's commitment to care was intimately related to feelings of filial obligation: "This was a year of many respiratory problems and I have always made an effort to accompany. I'm his son and this is my duty." --- [Simon]; "He's a bit anxious because of this disease and so I can't leave him when he drives and goes to the farm. I have to take care of him. " [David] For one participant, the sense of familial obligation was justified by a sense of guilt regarding the past. The reason for feeling guilty was related to the lack of attention with her mother before the onset of the disease. As John said: "The truth is: for a long time, I wasn't correct as a son. I didn't see the problems, I lived my life so quietly and I didn't worry… When I realised that we had problems, I recognised that maybe something had to change. If I was not the carer, nobody could be. I had to take care of my mother [silence] I was forced to be more present and closer." --- [John] Conciliating personal and professional life with caregiving. Three sons reported difficulties in conciliating their role as carers with the personal and professional life. Being a carer and a worker was a significant challenge. Some sons had to give up rewards and opportunities of career development to take care of their parents. Sons reported the lack of support from other family members that could help them in providing care, sharing commitments and responsibilities. They expressed the need to have time to provide care. --- "I lost many projects, both at professional and personal levels, due to having to care for my father. Unfortunately, health problems have also financial consequences especially because we have not a third person that I can say: 'I have a family member who will help us!' In fact, my sister does not help me taking care of him!" [Julius] "I need a job with some flexibility to be able to take care for my mother. Probably the severity of disease increases with age and it will require more of myself and I need flexibility at work" --- [John] Providing personal and intimate care. Four sons described constraints in providing personal and intimate care to their parents, such as bathing, dressing and toileting. Caring for parents with COPD was not only a daily challenge for sons , but also an ambivalent situation regarding their role as a man, child and, simultaneously, as a carer. Although three sons had never provided personal care to their parents, they were concerned and anticipated difficulties: "I had a grandfather who suffered from Alzheimer's disease and in his last six years he lived with us. I had no problems with bathing, shaving or dressing him, but that's because he was my grandfather. But my mom…she's a woman, it will probably be awkward. I am starting to convince myself that it won't be so troublesome, I hope, I will be strong enough, but I'm afraid." [John]; "What concerns me, and I know that it can happen, is the need to help my father [silence], dressing, take care of his hygiene, but I can't turn back." [Simon] One son used strategies to avoid getting involved in personal care but also to protect care receivers' intimacy, such as assigning this task to a female family member or care receivers' wore a bathing suit to protect privacy: "My wife and my daughter help me with my father's bathing; he wears a bathing suit. For now, we are doing like this. But --- if he gets worse I'll need help because I have no courage, he's my father. " [Julius] Becoming ill and be unable to provide care. The fears expressed by sons were focused on future dilemmas of care, anticipating the difficulties that have not emerged yet. All sons believed that, with COPD progression, parents would need more attention and care, and they feared not having the resources to support them. Specifically, two participants feared to become ill and not being able to provide care: "What I fear the most is that one day I'll also need help. I am afraid of getting the same disease and not be able to take care of him. " [Peter]; "Not being able to help her is my biggest concern. The worst is that in the future she will need me more than she needs today." [John] Information about COPD and self-confidence. All sons agreed on the importance of having information about their parents' disease, however, three recognised that they did not have sufficient knowledge. Sons mentioned they needed more information to become aware of the disease severity, to deal with the care receiver's breathlessness and to cope better with the disease: "It's essential to have more information about this disease and to know what I can do when my father is short of breath. I've never had information about his breathing problems." [Peter]; "I try to simplify information and to explain it to my father, such as how to use bronchodilators. But I need to know more. My father also needs more information to understand and accept the disease. The hardest part is the psychological pain, he needs emotional control. --- Sometimes, I don't have the skills to help him" [Simon] However, two sons stated that they had information about the disease, but they felt insecure about providing personal care. Despite this feeling of insecurity, a son reported that it was essential to convey confidence in care provision: "Yes, I consider that I have knowledge. But I can be wrong because it is in practice that we see if we are able or not. For example, when I need to provide another type of care I can tremble inside, but outside I will certainty say: 'let's go'! Transmiting confidence is crucial for her and for us." [John];"I have some knowledge. --- The problem is that if he becomes unable to perform basic activities of daily living, I don't have skills to take care of him." [Julius] Opportunity for personal growth. Four sons reported that the caregiving experience was an opportunity to learn more about themselves and to become aware of the strengths they did not know they had: "The positive part is that I feel more relaxed. I have learned to be more relaxed with his illness!" [David]; "It forces you to be more cautious, responsible, and more mature. --- Now, I have a higher sense of meaning and purpose in life" [John] Despite these positive impacts, one son was unable to identify any reward from the caregiving role. --- "Honestly, I can't see the positives aspects of this situation." [Peter] --- DISCUSSION This study focused on the men's experience in providing care to family members with moderateto-severe COPD. The general findings suggest that men are competent, nurturing and dedicated carers, however husbands and sons respond differently to the COPD caregiving experience. These differences reflected the relationship and the generational discrepancies. A strong sense of commitment to care was an overriding feature across the interviews. All men accepted this responsibility as "theirs", although the meaning of commitment varied between sons and husbands. For sons, a sense of filial obligation was very clear in their accounts, which for some came with personal and professional costs. Research found that feelings of filial obligation among son carers can predict a greater involvement in the caregiving role . However, sons encountered challenges and constraints associated with work and personal care conflict. Difficulties in balancing between full time job and caregiving responsibilities were reported, representing one of the most challenges described by the literature . Some had to give up promotional opportunities due to the caregiving demands and claimed the need for more flexibility from the employment entities. Another constraint was related to providing intimate care. Particularly, feelings of embarrassment and inappropriateness about seeing and touching the naked body of a frail parent were anticipated. Cross-gender taboos might explain these results, as it is less expected and accepted for men, than for women, to provide intimate care, particularly to mothers . For husbands, the caregiving seemed to be an extension of their marital role. Consistent with previous research, they appeared to face caregiving as part of their marital vows, in sickness and in health, and the result of a constructed ongoing reciprocity between spouses . Husband carers in COPD, like in cancer or dementia, were open to change household routines and to actively learn basic household tasks usually associated to the feminine role . Preserving the dignity and a sense of control of their wives was also present in the husbands' accounts, being part of what Bowers has described as preservative care. Despite the challenging nature of the caregiving role, husbands seemed to consider their experience as a "labor of love" , where the nurturing and emotional commitment are significant aspects of care to the point that they feel capable to do "whatever comes up" to protect their loved wives. However, husbands wished to gain more practical skills to deal with COPD, particularly those related to the management of acute exacerbations, one of their greatest fears, because patients are constantly "living in the proximity of death" . For husbands, anticipating their wives' death meant to lose a companion, a confidant and the unique source of emotional support. They desired a more adequate medical treatment towards their wives from the health care services. Previous research on general COPD caregiving have already recognised the ongoing uncertainty of acute exacerbation as a major stress factor , underlying the importance of having a "back-up", i.e., someone in the health care system to contact in a crisis . Moreover, COPD carers tend to be poorly informed about the long-term prognosis of their care receiver' disease or about what to expect toward the end of life, especially when compared with other diseases such as cancer or acquired immunodeficiency syndrome . In line with earlier studies , better support with symptoms control and more useful information about COPD course were important needs identified by both husbands and sons. The role of sons and husbands also differed in relation to caregiving intensity and function. Compared to sons, husbands provided more emotional and instrumental support , and were unique in providing personal and intimate care such as bathing. Again, the gendered nature of sociocultural assumptions and expectations towards caregiving might help to understand sons' less involvement in certain types of assistance, particularly personal care , which is probably provided by their own wives, i.e., the care-receivers' daughters-in-law. However, in line with recent studies , the current findings challenge the traditional assumption that men are not very much involved in household work or personal care, nor having the emotional acumen to deal with it. Despite the constraints of the COPD caregiving, participants found personal gains from the experience. For sons, caregiving was an important means for personal growth and development. Through their caregiving roles, sons have the opportunity to learn more about themselves and become aware of the strengths they did not recognised they had by learning how to successfully cope in different situations . For husbands, the experience represented an opportunity to be aware of their wives inner-strength and be encouraged by them, and to strengthen conjugal relationship. In particular, spousal carers who maintain continuity in their marital relationship , have been found to experience greater gratification from caregiving . Some limitations need to be acknowledged. This study was cross-sectional in design and conducted with a small sample of husbands and sons. Longitudinal studies with larger samples exploring how men's caregiving experience change over the course of COPD are still needed. Despite the small sample size, participants were identified through patients' records at primary health care centers, contributing to lessen sample bias. As underlined by Houde , methods of recruitment that rely on community support services for carers threats the sample's representativeness, as men are more hesitant to seek help or participate in support groups than women, thus those who participate may not represent men carers in general. Despite these limitations, our findings expand prior knowledge at least in two major ways. To the best of our knowledge, this is the first study to explore men's caregiving experience in COPD. Secondly, by differentiating husbands and sons carers' perspectives, it addresses a previous gap in research in which men are aggregated into the category "male carers", hindering the diversity of the caregiving experience shaped by birth cohort or family relationships. Various aspects of men's reactions to COPD caregiving however remains unexplored and need to be investigated. Additional efforts are required to determine the type of support services COPD men carers identify as relevant to their needs and if these differ according to their relationship to the caredfor person . --- CONCLUSIONS COPD is a major cause of disability which often leads to dependency on family carers. Men represent a growing group of carers for whom it is crucial to deepen theoretical, empirical and practical knowledge. This study extends the current caregiving literature by deepening understanding of the particular strengths and vulnerabilities faced by men as carers in COPD. Continued efforts to recognise men's experience in COPD caregiving role are determinant to understand if their needs are being adequately met.

Declaration of contribution of authors: DF and AM were responsible for the study conception and design. CJ and RG performed the data collection and analysis. DF was responsible for drafting the manuscript.

INTRODUCTION A sport club project refers to a venture or initiative undertaken by a sports club, organization, or a team. These projects can include a wide array of activities, such as building new facilities, launching new programs or teams, improving existing teams or facilities, and more . The goal of a sport club project is typically to improve the overall performance and success of the club, as well as to increase engagement and support from fans, members, and the community . There are various factors that can influence the success of a sport club project, including funding, resources, planning, and execution. It is important for sport clubs to conduct thorough research and planning before launching a project, with the aim of ensuring that it is well-designed, well-executed, and able to achieve its goals. Additionally, clubs should be mindful of the factors that influence consumer engagement and take steps to build strong relationships with fans and the community in order to secure their support for the project . In the project field of sport industry, the unique characteristics of sports have been determined, which indicate the importance of applying specific management techniques to sports organizations . A unique feature of sports is the presence of a large number of consumers who show an irrational passion for a sports club, competition or athlete . Stewart and Smith suggest that sports hold a symbolic meaning for consumers that is unique compared to other economic and social activities. This is because sports performance results and the celebration of team achievements evoke distinct reactions from consumers . The desire to understand consumer behavior in sports has been in the center of attention of sports club employees for a long time. The key to successful business in modern conditions is related to satisfying consumers by stimulating their desire to buy tickets for a sports event, purchase sports props, and reward loyal fans of a sports club . Also, the application of business mindset and using different management practices can help maintain tradition and connection with sentimental aspects of sports consumption and consumer engagement, but it is not necessarily a requirement. Other factors such as the target audience, industry trends, and external factors may also influence the approach to maintaining tradition and connection. Ultimately, it depends on the specific goals and values of the organization and its stakeholders. Consumer engagement refers to the level of interaction and involvement that a consumer has with a product or a brand . Project management, conversely, is the process of planning, organizing, and executing a specific short-term project to achieve a specific goal or objective . To achieve a successful business, it is important to not only attract new customers, but also retain current ones . This is where consumer engagement, loyalty, and satisfaction come into play, as they form the cornerstone for creating a positive brand image and establishing a loyal customer base. Hence, the purpose of this paper is to examine the impact of consumer engagement on trust, satisfaction, and loyalty in sports club social networks to create successful sport club projects. In terms of a product or brand, consumer engagement can be thought of as one aspect of the overall project. The project manager would be responsible for ensuring that the project is on track to meet the goals and objectives related to consumer engagement, such as increasing brand awareness or improving customer satisfaction. Conducting market research, developing a marketing strategy, and implementing tactics to increase consumer engagement are all important tasks that can help businesses maintain tradition and connection with nostalgic aspects of sports consumption. By understanding the target audience's preferences and interests, businesses can develop strategies that resonate with consumers and foster a sense of tradition and a connection with the sport. Implementing tactics such as social media campaigns, fan experiences, and merchandise can also help increase engagement and maintain the sport's traditions . This paper aims to explore the impact of consumer engagement on trust, satisfaction, and loyalty within sports club social networks. Consumer engagement is a key factor in fostering trust, satisfaction, and loyalty among fans and customers, and this study will specifically examine its influence within the context of sports clubs and their social networks. --- LITERATURE REVIEW In order to successfully manage a sport management project, it is important to have a clear understanding of the goals, objectives, and key performance indicators for the project. Additionally, effective communication, collaboration and leadership are crucial to align all stakeholders and to achieve the project's goals . The project manager would be responsible for ensuring that the project is on track to meet the goals and objectives related to consumer engagement, such as increasing brand awareness or improving customer satisfaction. This can include tasks such as conducting market research, developing a marketing strategy, and implementing tactics to increase consumer engagement. Social media has become an essential tool for sport clubs to engage with their fans and followers. Social media provides a platform for sport clubs to create meaningful relationships with their consumers, as well as promoting their brand and products . By engaging with consumers through social media, sport clubs can gather valuable feedback, and offer personalized content to meet the needs of their followers . Consumer engagement occurs in both online and offline settings, but the growth of social media has led to a rise in virtually engaged consumers . Several studies have examined the impact of motivation theory in the context of the online environment . The theory of motivation assumes that consumers are actively engaged and interactive when using social networks . Thus, it is important to tailor the theory of motivation to better understand consumer engagement on digital platforms. Consumer engagement can be formed and directed by the consumer's decision oriented towards the object of engagement, such as a brand, product, or a company . Analysis of existing research on consumer engagement . It is visible that the concept of consumer engagement is a multi-faceted construct that has been the subject of extensive research in the marketing field . The research has focused on defining and understanding the dimensions of consumer engagement; behavioural, cognitive and emotional being the most commonly recognized dimensions. The behavioral dimension focuses on the state of consumer behavior in relation to the object of engagement and the effort and energy put into the interaction. The emotional dimension is concerned with the emotional state and feelings associated with the object of engagement. And finally, the cognitive dimension refers to the level of thought and concentration that a consumer invests in an object of engagement, such as a brand, product, or service . It is important to note that these dimensions are interrelated, and that research has shown that emotional engagement can have an influence on the level of intensity of the behavioral and cognitive dimensions . This highlights the importance of considering the multidimensional nature of consumer engagement when designing marketing strategies or conducting research in the field. It is important to consider the different subdimensions of consumer engagement when conducting research or designing marketing strategies. These sub-dimensions provide a more nuanced understanding of the concept and help to paint a complete picture of the consumer's engagement with a particular object, such as a sports club . The consumer engagement can be seen as consisting of seven sub-dimensions identified by Dessart . They are identified as, attention, absorption, acceptance, enjoyment, enthusiasm, learning, and sharing. These subdimensions capture various forms of consumer behaviour that contribute to developing deeper relationship between the consumer and the sports club, surpassing the often-used loyalty metrics such as frequency of visits and purchase behaviour . While some authors support a one-dimensional perspective of consumer engagement , others emphasize the importance of considering other dimensions as well . This highlights the ongoing debate in the field of consumer engagement research and the need for further research to arrive at a consensus on the most appropriate perspective to take. Nevertheless, it is important to keep in mind the multidimensional nature of consumer engagement when conducting research and designing marketing strategies. --- RESEARCH HYPOTHESES AND CONCEPTUAL MODEL The Internet and digital platforms have fundamentally reshaped the way companies and consumers communicate, act, and do business with each other virtually . Digital marketing has become part of the marketing strategy. Marketers need to explore and understand how consumers use digital technologies to make decisions, how they choose brands, and how they do business with businesses using digital services . With the development of the use of the Internet and social networks, the number of consumers participating and doing business in the virtual world is increasing. Activities that take place on the Internet can be grouped according to the meaning that digital platforms have for consumers as a significant source of information, as a means of communication, a place of consumption, or as a place where consumers use digital platforms as a means of social inclusion . The consumer's behavioral manifestations towards the brand, analyzed outside of the purchase framework, are triggered by motivational factors, and the consumer's engagement is seen as a psychological state that is valued through the degree of the consumer's determination, commitment, absorption, and interaction . Research has shown that there is a direct correlation among consumer engagement and positive outcomes in the association between customers and a brand or product, including increased satisfaction, trust, and affective loyalty . Consumers are more inclined to join the virtual community of a sports club because of a sense of loyalty to the sports club. It is clear that consumers, who are members of the virtual community of a sports brand, already have an established fundamental relationship with the sports brand, which is further stimulated by participating in the virtual community of the brand . Consumer loyalty has been characterized as a fundamental driver for participation in a virtual community, and consumers join sports club social networks because of a sense of belonging and brand love . Thus, increasing consumer engagement can affect increasing consumer satisfaction, trust, and loyalty. --- A hypothesis is proposed: Engaging with sports club fans on social networks can positively influence their motivation and identification with the brand, leading to increased levels of trust, satisfaction, and loyalty among consumers who participate in these networks. Based on the study of the relevant literature, the following conceptual research model was proposed, shown in Figure 1. --- EMPIRICAL RESEARCH 4.1 Research methodology The empirical portion of the research involved administering a survey to both consumers and fans of team sports like football, basketball, and handball sports clubs. The sports groups selected for this study were chosen based on their overall popularity in society, as well as the size of their social media followings. Data was collected through a written questionnaire and an online form that was distributed through www.1ka.si in the period from June to December 2019. The questionnaire used constructs from previous research applied to the study context i.e., group spots. So, intrinsic and extrinsic motivation used a scale developed by . Intrinsic motivation integrates four dimensions: information, entertainment, personal identity, and brand love. Extrinsic motivation contains three dimensions: reward, empowerment, integration, and social interaction. Identification of consumers with members of the social network of the sports club used scale from and Identification of consumers with the sports club brand on social networks used scale from . Consumer engagement on the social networks of the sports club was measured with scale developed by . According to this scale, consumer engagement consists of emotional, behavioral, and cognitive dimensions divided into 7 subdimensions: attention and absorption , enthusiasm and pleasure , and sharing, learning and acceptance . Trust used a scale developed by , Satisfaction was measured with scale developed by and Loyalty used a scale developed by . All the scales used a seven-point Likert-type scale . Data was analysed using IBM SPSS version 20 and R statistical programs. --- Research results The research sample includes respondents who follow team sport's social networks of sports clubs . The typical respondent is male , resides in the area of the City of Zagreb , are under 35 years old , have a high school diploma , is a student or are employed and play sports recreationally . To test the proposed research hypothesis a mediation analysis was performed. Hence, 162 separate mediation analyses were carried out, whereby the independent variables represented the motivators of engagement on social networks of sports clubs and both dimensions of identification , the mediator variables represented the structure of consumer engagement in the social networks of sports clubs . The engagement outcomes of consumers on social networks of sports clubs represented dependent variables. In other words, the influence of each individual consumer motivator for participation in social networks of sports clubs and both types of identification, through each individual dimension of consumer engagement in social networks of sports clubs, was tested on each individual outcome of consumer engagement in social networks of sports clubs . Within this work, the PROCESS Procedure for SPSS Version 3.5.3 macro was used to assess the indirect effect and test its statistical significance. In the following tables , the summarized results obtained by running the macro command PROCESS Procedure are presented. The results of the study show that the relationship between consumer motivators for participating in sports club social networks and the outcomes of consumer identification, trust, satisfaction, and loyalty is not direct. Instead, it is mediated by consumer engagement on sports club social networks. The study found that consumer motivators, including entertainment, personal identity, reward, empowerment, information, integration, and social interaction, as well as consumer identification with both the members and brand of a sports club social network, influence consumer engagement on the network. This engagement is in turn linked to outcomes of trust, satisfaction, and loyalty. Based on these findings, the study's hypothesis is supported. --- DISCUSSION AND CONCLUSIONS This study contributes to the advancement of motivation theory within the context of customer engagement on sports club social networks. Our research indicates that both motivation and identification with the sports club's social network members/brand are statistically significant predictors of consumer attitudes towards the sports club's social network, as mediated by consumer engagement. Specifically, we find that engagement on the sports club's social network plays a crucial role in fostering identification, trust, satisfaction, and loyalty among consumers. Our findings are consistent with earlier work by Brodie et al. and Annamalai et al. which suggested that customer engagement is a key driver of trust and loyalty. We further note that the rise of virtually engaged consumers underscores the importance of investigating customer engagement on sports club social networks in contributing to the broader literature on this topic. Managerial implications for sports club marketing managers are seen in the possibility to use social networks more effectively with aim to improve project's success. Therefore, enhancing identification with other members/brand of the social network could include offering socialization events exclusively for social network members prior to the sport match to support sport club on stadium during the game or after to discuss the game, also could include live matches on social networks, interviews with sportsman or a contest that fans post their pictures on social network how they cheer their team. This consequently contributes to the realization and secures their support for the project to succeed. The research on consumer engagement in sports clubs might be limited by a small sample size, which could limit the generalizability of the findings. Cultural differences among the participants might not have been adequately accounted for and could impact their engagement with sports clubs. The studies might have only focused on a specific type of sport or geographic region, limiting their generalizability. A lack of a standardized definition of consumer engagement could lead to different interpretations and misunderstandings among researchers and practitioners. The findings of the studies might only hold for a specific point in time and might not be representative over a longer period. Selection bias in the studies could result in a skewed representation of the population. Selfreported data used in the studies could be subject to biases such as social desirability bias or recall bias, which could impact the accuracy of the findings. Overall, these limitations highlight the need for further research to address these gaps and to provide a more comprehensive understanding of consumer engagement in sports clubs. --- ACKNOWLEDGEMENT This paper has been supported by the University of Rijeka for project ZIP-UNIRI-130-8-20. --- International Journal of Market Research, 52, p. 801-826. Gammelsaeter, H., & Anagnostopoulos, C.

A sport management project refers to a venture or an initiative undertaken by a sports organization, team, or club to improve the overall performance and success of their operations. These projects can include a different range of activities, such as developing and implementing new strategies, launching new programs, creating a new fan engagement program to increase support and loyalty, and more. This study examines the influence of sport's fan engagement on trust, satisfaction, and loyalty in sports club social networks. Our findings suggest that both fan identification with the sports club's brand and motivation play significant roles in determining the level of engagement. Specifically, we have found that consumers who have a strong identification with the club and are extrinsically motivated to engage with the club's social network exhibit higher levels of trust, satisfaction, and loyalty. These results underscore the importance of fostering a strong sense of identification and motivation among fans in order to promote positive consumer attitudes towards sports club social networks. The paper provides recommendations for sports club marketing managers on how to use social networks to improve project's success.

Introduction A new coronavirus disease, caused by the SARS-CoV-2 virus and identified as COVID-19, was first acknowledged in China in 2019 and rapidly became a global threat to the health of many employees working in the social and health care sectors. There is evidence that COVID-19 has a disproportional impact on health care workers both physically and psychologically, causing a high incidence of disease, death, and a number of psychological problems, including stress, depression and anxiety [1][2][3][4]. Although psychological symptoms have been found to be particularly high among those working on the frontline during the pandemic [5][6][7][8], non-frontline heath care workers have also reported such symptoms [9]. Moreover, these symptoms have been more severe among females and younger workers [4,10,11], as well as for those with prior mental health problems [12,13]. In addition to these cases, social sector workers, who have seldom been acknowledged in the recent COVID-19 literature, have also faced risk of infection in their work [14]. For example, in England and Wales, social care workers had a significantly raised rate of death between March and May 2020 [2]. It is clear that COVID-19 is causing psychological stress to social sector and health care workers due to the increased risk of personnel infection, fear of spreading the disease, concern for one's own family if one becomes sick [3], lack of knowledge on the disease as well as deaths among other professionals [15]. On the one hand, perceived health risk is important in order to motivate individuals to engage in health-protective behaviors [16]. On the other hand, the perceived risk is associated with increased stress symptoms, in particular when the management of the risk is at least partly beyond one's own behavioral control [17,18]. Among health care and social sector workers, the perceived infection risk is dependent on the protective measures taken by organizational infrastructures and governments. Accordingly, confidence in protective measures has been found to be associated with reduced psychological symptoms [13,19,20]. Various protective strategies against COVID-19-related occupational stress and its negative effects have been considered, ranging from resilience enhancement to providing adequate organizational support systems [12][13][14]. Curiously, in the context of social sector and health care workers, the role of organizational group processes has rarely been discussed. According to the "social cure" perspective to social identity, group membership has a positive impact on well-being and health [21]-an association shown to be prevalent among medical service workers [22]. Groups can provide powerful psychological resources to their members, such as social support, which can reduce stress symptoms [23][24][25]. For example, people who identify with a group perceive other group members' social support more positively than people who do not. In addition, those reporting high levels of work community identification are more confident of receiving support from other group members when needed than those less inclined to identify [23,25]. Thus, when occupational organizations consider protective strategies against stress that is related to COVID-19 infection risk at work among social sector and health care workers, promoting identification with their work community might be one key protective factor that can buffer this stress. This article analyses the combined effect of the perceived risk associated with COVID-19 infection at work with work community identification on psychosocial well-being among health care and social sector workers in Finland. We analyze both groups because in Finland, social sector and health care workers often work in the same organizations and institutions as part of multi-professional teams. To our knowledge, the buffering effect of group identification on the relationship between perceived health risk and stress symptoms has yet to be empirically tested. Drawing on the "social cure" perspective [25], we test our main hypothesis that those social sector and health care workers who report both a high perceived COVID-19 infection risk at work and low work community identification suffer significantly more often from stress symptoms than those who report high perceived COVID-19 infection risk and high work community identification. --- Materials and Methods --- Participants and Procedure The data were collected through The Union of Health and Social Care Professionals in Finland, which distributed the invitation and the link to an online questionnaire to its members. In total, 1555 members filled in and submitted the online questionnaire, with a response rate of 5%. In the first page, participants were informed about the aim of the research and had the opportunity to scroll through the form before answering questions; participants were not obliged to respond to any of the items, ensuring full voluntarism could be guaranteed, and informed consent was positively required. Only participants who provided informed consent, were in paid or salaried employment, and were 18-64 years old were included. The final sample included 1279 participants. The data were collected between 28 May and 16 June 2020 using the Limesurvey program. The Ethics Committee of the Tampere Region approved this study . --- Materials --- Outcome Variable The outcome measure was self-reported stress symptoms measured by four items: "during last two months, how frequently you have suffered from": fatigue, apathy or lack of energy; difficulties in falling asleep or recurrent awakenings at night; tenseness, nervousness or irritability; feeling that it is "all just too much"? These items were drawn from the Finnish Quality of Work Life Survey [26] and have often been used as indicators of stress and mental exhaustion [27,28]. In these analyses, the items were measured on a five-point scale, with the number selected corresponding to the frequency of symptoms experienced: 0 = never, 1 = less often, 2 = once or twice a month, 3 = a few times a week, and 4 = almost daily. The items were summed and then divided by the total number of items the participants responded to. The rate was calculated if at least two items were answered. The reliability was good . --- Predictors The perceived risk associated with COVID-19 at work was measured by one item: How likely do you consider the following things will happen in relation to your work in six months: I will have COVID-19 infection in my workplace. A similar item has been used elsewhere [29]. See also [30]. The response scale varied from "very likely" to "very unlikely" . Responses reporting that the risk had already materialized , as well as those who reported that the question did not apply to them , were coded as missing values. The item was recategorized with 0 corresponding to the risk is unlikely , 1 corresponding to the risk is intermediate and 2 corresponding to the risk is likely . The work community identification was measured by two items adapted by Doosje et al. [31,32]. The five response options varied between 'totally disagree' and 'totally agree' . The items were summed and divided by the number of items = 1.43). The rate was calculated if at least one item was answered. Responses reporting that the question did not apply to them were coded as missing values. The reliability was good . Then, the summed variable was recategorized into two categories, using the mean as a cut-off value . Finally, we formed one new combined variable. We combined perceived risk at work and work community identification as follows: 1 = low risk and high identification, 2 = low risk and low identification, 3 = medium risk and high identification, 4 = medium risk and low identification, 5 = high risk and high identification, and 6 = high risk and low identification. --- Background Variables The background variables were gender, age, number of people living in the household, highest level of education, occupational group, working time pattern and whether the participant belonged to a COVID-19 infection risk group. The working time pattern was controlled because shift work is associated with insomnia [33]. The occupational group was determined through the following response options: 0 = social sector work and 1 = health care work. If requested, participants had the possibility to report another occupational group. In total, 11 participants reported that they worked both in social sector and health care work. Due to the small frequency of this latter category, it was not included in the analysis and was coded as a missing value [34]. A further 9 participants reported that they worked in the education sector. These participants were categorized alongside those who worked in the social sector . In addition, we controlled the perceived risk associated with COVID-19 in one's spare time : How likely do you consider the following thing will happen in your spare time in next six months: I will have COVID-19 infection in my spare time. The response scale varied from very likely to very unlikely . The item was recategorized as the perceived risk at work, as explained above. Responses reporting that the risk had already materialized were coded as missing values. Finally, we assessed trust in the Finnish authorities by a single item: I trust the Finnish authorities in their treatment of the coronavirus pandemic. The response scale varied from totally agree to totally disagree . --- Statistical Analyses The effects of all the variables on perceived risk at work and work community identification were examined using cross-tabulations and analyses of variance. The effects of all the variables on stress symptoms were examined using analyses of variance and Pearson correlation coefficients. The main and combined effects of perceived risk at work and work community identification on stress symptoms were subjected to an analysis of covariance . This analysis was carried out using IBM SPSS Statistics for Windows, Version 25.0. The missing data were handled by using listwise deletion. The percentage of missing data varied from 0% to 10% . The mean of the missing values was 2% per variable. --- Results The majority of the participants were women, aged between 35 and 44 years, and had tertiary education. Table 1 presents the frequencies and means of all the variables, as well as their associations with the predictors and the outcome variable. In total, 41% of participants reported a high risk of COVID-19 infection at work. Perceived risk at work was significantly associated with all background variables with the exception of gender, highest education, occupational group, and belonging to a COVID-19 risk group . The risk perception decreased with age, so that whilst 67% of the youngest age group reported a high risk, only 32% of those in the age group 55-64 reported the same. Those who reported medium risk lived in significantly bigger households than those who reported low or high risk . A higher percentage of those who had two-shift work , three-shift work or who worked atypical hours reported a higher COVID-19 infection at work than those who had regular day or evening/night work . In addition, 18% of participants who reported high perceived risk at work also reported high perceived risk in their spare time, whereas the percentage among medium-and low-risk groups was 8% and 7%, respectively. Finally, those who reported high risk had significantly less trust in the Finnish authorities to effectively manage the Coronavirus pandemic than those who reported low or medium risk . There was no significant association found between perceived risk and work identification. From the background variables, the work community identification was only significantly associated with working time patterns and having trust in the Finnish authorities . Those who had three-shift work, or worked atypical hours, reported higher work identification than those in two-shift work , regular day work , or regular evening or night work . Finally, those with low work identification had less trust in the Finnish authorities to manage the pandemic than those with high identification . Stress symptoms were significantly associated with all the background variables except the number of people living in the household, occupational group, working time pattern and perceived risk in spare time . Women reported stress symptoms more often than men , participants from the age group 25-34 reported symptoms the most often and their stress level differed significantly from all the others except those in the 18-24 age group. Similarly, those who had secondary education reported these symptoms more often than those with tertiary education . In addition, participants who belonged to a COVID-19 risk group reported stress symptoms more often than those who did not . Finally, the lower the level of trust participants reported in the Finnish authorities to manage the Coronavirus pandemic, the greater the propensity to report stress symptoms. Both predictors were significantly associated with stress symptoms . Participants who perceived a high risk of COVID-19 infection in their workplace reported stress symptoms more often than those who perceived only a medium or low risk. This association was still significant after all the background variables were included in the model = 30.84, p < 0.001, ηp 2 = 0.06). Estimated marginal means and standard errors of unadjusted and adjusted models are reported in Table 2 below. Similarly, participants with low work identification reported stress symptoms more often than those with high work identification. Once again, this association was still significant after all the background variables were included in the model = 13.87, p < 0.001, ηp 2 = 0.01). Estimated marginal means and standard errors of unadjusted and adjusted models are reported in Table 3. In light of these results, we examined the combined effect of perceived risk at work and work community identification on stress symptoms. The estimated marginal means, standard errors and pairwise comparisons of unadjusted and adjusted models are reported in Table 4. In the unadjusted model, the combined effect was significantly associated with stress symptoms = 22.01, p < 0.001, ηp 2 = 0.09). Participants who reported high perceived risk and low work identification reported stress symptoms with significantly greater frequency than those who reported high perceived risk and high identification. All the mean differences between this category and other combined categories were significant. After inserting all the background variables into the model, the combined effect was still significantly associated with stress symptoms = 15.25, p < 0.001, ηp 2 = 0.07). Similarly, the means of participants who reported both high risk and low work identification still differed significantly from all the other categories. There were no statistically significant interactions between perceived risk and work identification in the unadjusted = 0.43, p = 0.650) or fully adjusted models = 0.49, p = 0.611). *** <0.001, ** <0.01, and * <0.05. a p = 0.004, b p = 0.010, c p = 0.022, d p = 0.015, e p = 0.009, f p = 0.018, g p = 0.001, h p = 0.041, i p = 0.002, j p = 0.014, k p = 0.007, l p = 0.026, m p = 0.021, and n p = 0.003; --- Discussion Our results support the hypothesis that those with low work community identification and high perceived COVID-19 infection risk at work show greater frequencies of stress symptoms than those with high identification and high perceived infection risk. The former group differed significantly from all other comparison groups in reporting the most stress symptoms. In addition, participants who reported high work community identification and low perceived COVID-19 infection risk at work reported significantly fewer stress symptoms than any other group. Finally, participants who reported a medium infection risk and low identification only showed significant differences from those who reported either high risk and low identification or no stressors at all . These findings show that higher levels of work community identification may act as a buffer against stress factors in the field of social sector and health care work, especially when employees perceive a high health risk in their workplace. As the social cure model argues, group identification is an important source of security, support and belonging and its effect on well-being has been demonstrated in many studies [25]. To our knowledge, however, this is the first study which has demonstrated this relationship in the context of the COVID-19 pandemic and risk perception. Our results contribute to the extant literature in a number of other ways. First, the findings lend support to previous analyses reporting a link between risk perceptions and stress [17,18] by showing a strong relationship between higher perceptions of COVID-19 infection risk in the workplace and the increased frequency of stress symptoms. Secondly, work community identification and stress symptoms were also related. Participants reporting low levels of work community identification also reported stress symptoms more often than those reporting high levels of work community identification. This also supports findings that have been found before, albeit in a different context [35]. In contrast, work community identification and COVID-19 infection risk at work were not significantly associated with each other. This contradicts previous research suggesting that the greater the identification with a group, the lower the perceived risk is likely to be [36,37]. This claim was predicated on the basis that group identification increases trust. Although it is likely that this occurs in particular contexts [38], this is unlikely to be the case in all circumstances. One important factor that might explain this inconsistency is the degree to which people are able to control their risk. In our cases, social sector and health care workers rarely have sufficient control over the risk factors, or necessary resources, that are able to make meaningful reductions to their perceived risk . Thus, people can report high levels of work community identification, and exhibit high levels of trust, but if the loci of risk controls are out of reach of the community, then group identification is unlikely to relate positively to perceptions of risk. This opens an important avenue for future research, namely, to explore in greater detail, and in more diverse contexts, how levels of control over risk-management resources affect the relationships between group identification and risk perception. Finally, empirical research that has analyzed the well-being of social sector workers during COVID-19 pandemic is rare [14]. Our social sector and health care workers did not significantly differ in risk perception, work community identification or frequencies of stress symptoms. These occupational groups often work in the same organizations and institutions as part of multi-professional teams and thus share the same COVID-19 risk. More research analyzing the well-being of social sector workers is needed in the context of COVID-19. Our results have strong practical implications. The findings can make a valuable contribution to the development of strategies for social sector and health care professionals to maintain their well-being under stressful working conditions during the COVID-19 pandemic. Given that risk perception and stress are mutually related [17,18], their interplay may produce a vicious circle which can end up in exhaustion and burn out. The social cure approach suggests that developing greater group identity is a powerful psychological resource in a such context [25]. Our results highlight the role of work community identification in contributing to social sector and health care workers' ability to cope with stressors that cannot be avoided at work. For example, employers can strengthen the sense of community in their organizations by providing opportunities to share experiences within the group in a safe way and develop mutual trust as well as by recognizing and acknowledging the powerful role of collective strategies that the work community has successfully used in the past and adapting them to current environment [22]. Naturally, our findings have their limitations. The data are cross-sectional; thus, our reasoning is strongly based on previous research and theories. In addition, although our sample was representative of members of The Union of Health and Social Care Professionals in Finland, the response rate was lower than we would have preferred, and it is possible that those with higher levels of concern about their work condition had a greater motivation to answer than those who perceived that their work conditions were risk free or of low risk. These factors limit the generalizability of the results. In addition, the effect size was quite small. Although work community identification may act as a buffer, practical factors such as having enough personal protective equipment are of course essential for controlling the stress caused by COVID-19 infection risk. Cross-cultural, longitudinal and experimental data are needed to confirm the findings. --- Conclusions Our findings have shown that participants who report low work community identification and high perceived COVID-19 infection risk at work were significantly more stressed than other participants. This finding indicates that the combined effect of work community identification and risk perception needs to be considered in efforts to reduce the psychological stress social sector and health care workers face during the COVID-19 pandemic. Our findings provide further support to the notion that group processes are essential to people's psychosocial well-being and that this is especially salient in times of health crises. --- Author Contributions: Conceptualization, E.F.; methodology, E.F.; formal analysis, E.F.; investigation, E.F.; writing-original draft preparation, E.F. and A.V.; writing-review and editing, E.F. and A.V.; funding acquisition, E.F. All authors have read and agreed to the published version of the manuscript. ---

It has been well documented that both risk perception and group identification are related to psychosocial well-being. However, their combined effect has rarely been analyzed. We examined the combined effect of perceived risk associated with COVID-19 infection at work and work community identification on psychosocial well-being (i.e., frequency of stress symptoms) among health care and social sector workers in Finland (N = 1279). Data were collected via an online questionnaire in June 2020 and analyses of covariance were conducted. Perceived COVID-19 infection risk at work was classified into high, medium and low risk. In total, 41% of participants reported a high risk. After all background variables were included, participants who reported high perceived infection risk and low work community identification reported stress symptoms more often than those who reported high perceived risk and high identification (p = 0.010). Similarly, the former differed significantly from all other comparison groups (medium and low risk, p < 0.001), being the most stressed. We found that perceived infection risk and work community identification were not related to each other. Our conclusion is that high work community identification can buffer employee stress when faced with a high perceived health risk. In the context of the COVID-19 pandemic, work organizations with a high infection risk should advance the possibility of employees' identification with their work community.

Introduction The size of the Asian American population living in the U.S. is projected to increase by 132% and will comprise 9% of the total U.S. population by 2050 . As compared to Whites, Blacks, and Hispanics, Asian Americans have distinctive profiles for leading causes of death. Specifically, cancer is the leading cause of death for Asian Americans. Specific information on Asian American subgroups indicates that Korean Americans have the highest cancer mortality rates and the lowest breast and colorectal cancer screening rates . Korean American men and women have the highest incidence of stomach cancer compared to other Asian subgroups, which is five times higher than rates for non-Hispanic White men and seven times higher than non-Hispanic White women . Korean American women have the highest incidence and mortality rates for liver cancer compared to other Asian American subgroups, while Korean American men have the second highest incidence and mortality rates for liver and colorectal cancer . Given the high incidence of cancer among Korean Americans and the dramatic increase in the percent of Korean Americans living in the U.S. since 2000 , oncology professionals will likely be caring for more Korean cancer survivors and will need more accurate and culturally and ethnically relevant information about their cancer experience, quality of life , and factors that affect it. One of the persistent problems in understanding the experience of Korean Americans with cancer is that current studies often focus on Asian Americans as one large homogeneous group, a practice that obscures the heterogeneity that exists within the Asian American population . Past epidemiologic studies indicate that lifestyle factors, genetics, nativity , socioeconomic, and environmental factors may influence the development of cancer and survival among immigrants. However, these findings vary by specific ethnicity designations within the broader racial categories . Using aggregated data to represent all subgroups of Asian Americans, hinders understanding of the diversity that exists both across and within these subgroups . Further, aggregated data obscures the identification of risk factors and causes of mortality within each group, and also decreases the ability to tailor interventions to the unique needs of specific subgroups of Asian Americans . The present study uses an integrative review of the literature to address the limitations of aggregated data from multiple Asian American subgroups and increase understanding of Korean Americans' cancer experience. The integrative review focused specifically on Korean American cancer survivors and examined their QOL and factors that affected it. This information is essential for fostering a better understanding of the cancer experience in this group and planning culturally/ethnically appropriate interventions to support them. In this review, the term "cancer survivor" refers to a person who has been diagnosed with cancer, including anyone who is currently getting treatments for cancer as well as those who have been treated for cancer and are presently cancer free. --- Characteristics of Korean American Immigrants The majority of Koreans came to the U.S. after Congress passed the Immigration Act of 1965 that enabled people from other countries to seek a better life, pursue their education, and join family members living in the U.S . Currently, the top three states where most Korean American immigrants live are California , New York , and New Jersey . About 40 percent of Korean immigrants live in metropolitan areas such as Los Angeles, New York, and Washington D.C. . General demographic characteristics of Korean American immigrants in the U.S. indicate that more than half are foreign-born , 52 percent have a bachelor's degree or higher , and among Asian American subgroups, they have the highest rate of selfemployment . Compared to the six largest Asian American subgroups , Korean Americans have the lowest median household income despite having high educational attainment. --- Korean American Cancer Survivors' Cultural Values and Quality of life Research indicates that Korean American cancer patients' QOL is strongly influenced by their cultural norms , which are based on Confucianism. In Confucianism, gender and familial roles are clearly delineated. Traditionally, men are the breadwinners and decision makers for the family . Women are obligated to cook for the family, raise children, maintain the household, and help financially. These cultural norms shape family members' expectations that wives and mothers who are diagnosed with cancer will continue their usual cultural/ gender roles as caregivers and in managing the household. This conflict between expectations and the experience of living with cancer and its treatment creates enormous strains that negatively impact the emotional well-being of female cancer survivors . Although the literature on the QOL of Korean American cancer survivors is limited, prior research indicates that Korean American cancer survivors have lower levels of acculturation and lower quality of life when compared to other Asian cancer survivors . Korean American cancer survivors also report lower psychological QOL than their native Korean counterparts, but higher physical QOL . Korean American cancer survivors report difficulty adjusting to cancer due to language barriers they face that hinders their understanding of health information and ability to communicate with health professionals . In sum, due to the small number studies in this area and acknowledged limitations of the literature, little is known about the QOL of Korean American cancer survivors. More information is needed on their QOL and associated factors in order better to understand and plan culturally/ethnically appropriate interventions to support them. This integrative review was conducted to assess the current state of the literature and to gain a better understanding of QOL issues among Korean American cancer survivors. --- Literature Search This integrative review was conducted with focused searches using PubMed, CINAHL, Google Scholar, and EBSCO databases and were limited to studies published from January 2000 to January 2014. Searches were conducted using the following key words Korean American or Asian American cancer patients or survivors' experiences or quality of life including at least the word quality of life with either Korean American or Asian American, which were used as exploded Medical Subject Headings terms. For example, using the search "Korean American cancer survivors' quality of life" and the MeSH terms of Korean American, cancer survivors, quality of life were used in the PubMed database. Both English and Korean language publications were retrieved. Studies were included if they were primary quantitative, qualitative, or mixedmethod studies that described the experience of Korean American cancer survivors and factors that influenced their quality of life. Studies that were based on samples that focused broadly on quality of life of Asian Americans, but that reported the results for Korean Americans as a specific subgroup, were included in the review. Quotes from a qualitative study among Asian American cancer survivors were also included in this review, if the quote was directly attributable to a Korean American cancer survivor. --- Data Evaluation Prior to data analysis, potential studies were reviewed by four researchers and any discrepancies were resolved by evaluating the overall quality of each study. Each study was rated on a 2-point scale based on the relevance of findings to the purpose of the review . Also, studies were evaluated for adequate conceptual definitions of variables, appropriate use of research design and method, and appropriate data analyses. --- Data Analysis Data from all studies included in the integrative review were extracted. The most commonly measured variables in the quantitative studies, and the most commonly discussed issues in the qualitative studies that affected QOL of Korean American cancer survivors reflected 3 main themes: social support , communication , and acculturation . --- Presentation of Findings A total of 13 studies that included Korean American cancer survivors were retrieved from the search: 7 quantitative studies, 5 qualitative studies, and 1 mixed-method study . Table 1 provides details about the 13 studies. All studies were obtained in English except one qualitative study that was written in Korean by Choi and colleagues . Two studies consisted of Korean Americans only, nine studies included Korean Americans with other Asian American ethnic groups, and two studies compared native Koreans to Korean Americans. The number of Korean Americans in the studies ranged from less than 10 to a high of 71 . --- Demographic Characteristics The mean age of the cancer survivors was 56 years. A majority of participants in the studies reviewed attained more than a high school degree and had an average income level of less than $25,000. Cancer survivors' average length of stay in the U.S. was 21.8 years and 98% of them were born in Korea. Of the thirteen studies reviewed, all were conducted with female cancer survivors. Most studies were conducted with women with breast cancer and a few were conducted with women with gynecologic cancer . Korean American breast and gynecological cancer survivors generally had lower income but higher education than their native Korean counterparts . Korean American breast cancer survivors had the lowest income compared to other Asian American breast cancer ethnic groups and also the lowest level of QOL . Several socioeconomic indicators predicted or were related to QOL. Income was inversely associated with psychological distress and positively associated with QOL . Higher education was associated with positive physical and mental QOL . In regard to acculturation factors, language barriers were identified as a primary indicator of Korean American cancer survivors' level of acculturation. Higher levels of acculturation were positively related to their level of QOL. High language barriers were related to lower social network involvement . Longer length of stay in U.S. was positively associated with larger social network size, greater social involvement, and fewer language barriers . --- Social Support Perceptions of Korean American Cancer Patients and Caregivers Studies included in the integrative review documented the importance of social support for Korean American cancer survivors' QOL. Higher perceived social support was one of the factors that positively influenced higher levels of well-being in a study of Korean American gynecological and breast cancer survivors . Social support was also negatively associated with psychological distress , and the positive impacts of spirituality for better overall QOL was mediated via perceived social support . Lim also found that breast cancer survivors who used more social support from extended family, friends, and neighbors, or sought more spiritual support had better mental-related QOL. Furthermore, those with positive social network structures had better emotional support and QOL . These studies all suggest that social support is a key factor related to Korean American cancer survivors' QOL and that social network size and network involvement have a positive influence on emotional support. However, Korean American cancer survivors had significantly smaller networks and less network involvement as compared to their native Korean cancer survivors . Five qualitative studies found that family was perceived as both a major source of support and a major source of stress for Korean American cancer survivors. Perceived stress can be attributed to survivors' adherence to ethnic values that emphasize the importance of fulfilling family role expectations even after receiving a cancer diagnosis. Perceiving family as a source of stress was also associated with survivors' belief that their family members did not know or understand what they were really going through . For example, a breast cancer survivor said "My family expects me to work and function the same as before the surgery. It saddens me" . Elderly Korean American cancer survivors reported that it was difficult to seek support from younger adult family members because they did not want to become a burden by relying on them too much. Elderly survivors felt cancer was their battle to wage alone . To illustrate, a Korean American oncologist said "Older generations feel that they are a burden to their family, so that's another different issue that some of my patients do go through ." . Obtaining support from the community was also difficult for Korean Americans. Studies indicate that cancer survivors wanted support groups to share feelings and experiences , but were not able to locate support groups that were language appropriate . Further, because many community members were immigrants who had demanding work commitments for surviving through immigrant life, cancer survivors did not perceive that they had much support from their own Korean American community. Korean American cancer survivors also perceived a lack of support from the Western community . Language barriers were a primary reason that limited their ability to relate and share their feelings freely with people from the Western community. One cancer survivor said "Americans don't seem to share their emotions with immigrants like us. They don't try to talk to us first." . Direct quotes are provided in Table 2. As a consequence, cancer survivors were unable to receive emotional support from either the Korean or Western communities . --- Communication and Cancer Several quantitative studies examined the relationship between Korean American's communication behaviors and their physical and mental QOL. Lim found that cancer survivors who communicated effectively within the family improved their own physical and mental QOL . Similarly, among 71 Korean American breast cancer survivors, family communication was directly associated with mental and physical QOL . Other studies focusing specifically at family relationships found that higher family support was related to more family communication . Communication within a family was sometimes a barrier for Korean American cancer survivors. Choi et al.'s qualitative study of first generation Korean American breast cancer survivors found that although their main emotional support came from family members, cancer survivors had difficulty communicating with their second generation adult children due to language barriers. Adult children were more fluent in English and firstgeneration immigrant cancer survivors were more fluent in Korean. First-generation Korean American cancer survivors identified this language barrier as an obstacle to receiving adequate emotional support from their family. Korean American cancer survivors also perceive that cancer-associated stigma has limited their ability to effectively communicate with their family members and others. Some Korean American cancer survivors felt ashamed of having cancer, which made them reluctant to talk about their feelings with others who were healthy . Because of the stigma, they also limited their interactions with others but then felt lonely and distressed. By hiding their cancer, Korean American cancer survivors were able to avoid hearing negative comments or questions such as "how much longer ?" . They indicated that negative comments from others were difficult to hear and had a negative effect on their QOL . Feelings of shame for having cancer and the need to protect themselves from others' comments, were reported mainly by female cancer survivors whose observance of cultural norms prevented them from sharing their experiences . Studies examining communication and the relationships between Korean American cancer patients and their physicians found physicians' assistance in managing patients' stress had positive effects on QOL. In qualitative studies, Korean American cancer survivors reported that their doctors' attitudes and communication was important to them during their cancer treatment and follow-up care . However, some Korean breast cancer survivors said that they worried that asking too many questions could result a negative relationship with their physicians. This was not the belief of other Asian subgroups, who felt that patients should ask their physician questions . In general, first generation cancer survivors said they preferred a Korean-speaking oncologist because they would be able to understand information about their course of disease more easily . However, it was difficult for the survivors to find a Korean-speaking oncologist within their Korean American community. Further, Korean American cancer survivors said they were limited to those hospitals or oncologists that were covered by their insurance. This hindered their ability to find a Korean American oncologist who also spoke Korean and with whom they could have effective communication. --- Acculturation Degree of acculturation to their host culture is highly related to health-related QOL . In studies of Korean American cancer survivors: 1) higher acculturation influenced their multi-dimensional QOL through better social support , and 2) higher acculturation was directly related to higher social support . In both studies, the degree of acculturation was assessed using measures of cultural identity and knowledge, language use, and food and diet patterns, as well as additional acculturation factors such as, birthplace, primary language/language barriers, and length of stay in the U.S. Studies of acculturation indicated that Korean American cancer survivors were much less acculturated as compared to Chinese cancer survivors, even with comparable lengths of stay in the United States . Further, those who completed surveys in English were more acculturated than those who completed surveys in their own native language. Among Asian groups , Korean Americans had the highest rate of completing surveys in their own language, suggesting lower levels of acculturation . Acculturative stress is a common response to the process of acculturation that is reflected in lower mental health status , higher psychosomatic symptom level, and identity confusion . Factors associated with acculturative stress can lead to lower levels of QOL among immigrant cancer survivors versus non-immigrant cancer survivors . Immigrants who are diagnosed with cancer reported compounded stress from a variety of sources, in addition to the stress of being an immigrant. Korean Americans who receive a cancer diagnosis reported more stress from 1) a lack of knowledge or education related to understanding of the U.S. health system and finding resources, 2) language barriers related to understanding health-related materials after surgery, chemotherapy instructions, or side effects from clinicians, 3) a lack of support and availability of Korean cancer support groups, and 4) having to work while being treated for cancer due to lack of insurance and need to support their immigrant family. Findings from qualitative studies indicate that cancer survivors had limited understanding of the U.S. health care system related to its high-cost and fragmented care system and had a lack of trust in the system . Also, breast cancer survivors did not have knowledge or education specific to cancer genetic testing or about the need for cancer screening in situations of a family history of breast cancer . Finally, because of their limited English and language barriers, Korean American cancer survivors played a less active role in their treatment plan and they were less likely ask questions or express concerns . --- Discussion This integrative review identified 13 studies focused on factors affecting the QOL of Korean American cancer patients. The most common factors or topics that were studied were social support, communication, and acculturation, which all demonstrated significant relationships to QOL. More specifically, higher family support, better family communication, and higher level of acculturation, were associated with higher quality of life among Korean Americans. The central findings of this review are that Korean American cancer patients: 1) received inadequate social support from both their own ethnic community and the western community, 2) had difficulty communicating with their adult children, 3) experienced stigma from having cancer, 4) were not able to receive health information in their own language, and 5) experienced acculturative stress which hindered effective communication with others and ultimately affected their QOL. These findings are consistent with a literature review of studies of Asian American breast cancer survivors living in the U.S. . In that literature review, quantitative studies indicated that cultural health beliefs, immigration stress, acculturation level, English proficiency, social support, and spirituality were associated with Asian American breast cancer survivors' quality of life. The qualitative studies indicated that cancer survivors reported a lack of physical and emotional support, a lack of knowledge, and language barriers during cancer survivorship. An important finding from this review of quantitative and qualitative studies was that Korean American cancers survivors are often uncomfortable or uncertain about interacting with their oncologists. Korean American cancer survivors were hesitant asking questions and worried that if they asked too many questions, it would have a negative effect on their doctor-patient relationship. Female Korean American cancer survivors often deferred to their physicians when considering treatments, were less active in the decision making process and often wanted to follow their doctors' recommendations to promote a good relationship . Korean American deference to their physicians may be associated with the fact that most of them were elderly, first generation immigrants who were strongly influenced by their Koran cultural beliefs, and less likely to be acculturated. The integrative review also indicated that because families are the main source of social support for Korean American cancer survivors, it is important to include family caregivers of cancer survivors in future studies. However, caregiving is a part of cultural obligations in Korean culture . Given this, a full appreciation of the cultural meaning of caregiving will be crucial for assesing the patient-cargiver relationship. Past studies indicate that Korean American caregivers have higher levels of depression, burden, and anxiety than White Americans caregivers suggesting that they may also have needs for specific types of information and support as caregivers. --- Direction for Future Research Given the paucity of research on Korean American cancer survivors, there is a need for more research including descriptive, exploratory, and longitudinal studies that focus only on Korean Americans. Studies with larger samples of Korean American cancer survivors will further clarify the relationships between social support, communication, acculturation and QOL. Also, future studies will need to assess Korean American cancer survivors with different types of cancer. In light of the high incidence of stomach and liver cancer among Korean Americans, it is surprising that none of the studies included survivors with these types of cancer. In addition, because Korean Americans have the lowest use of cancer screening compared to other Asian subgroups, studies focusing on increasing cancer screening using culturally tailored interventions are needed. --- Limitations of Existing Literature This review is constrained by a number of limitations in the existing literature on the QOL of Korean American cancer patients and caregivers. First, only two studies focused exclusively on Korean American cancer survivors. Although the remaining studies included Korean American as one subgroup of Asian Americans, analyzing the experiences of only Korean American cancer survivors was challenging. Second, studies in the integrative review were focused on breast/gynecological cancer survivors , which limited our understanding of the relationship between support, communication and acculturation among survivors coping with other types of cancer. Also, the findings may be relevant primarily to female Korean American cancer survivors who made up the sample for most of the studies reviewed. Third, the majority of the studies were conducted by the same team of researchers using a few large surveys, which may limit the generalizability of the findings. Fourth, most of studies had small sample sizes. Finally, the research designs in prior studies were primarily secondary analyses, crosssectional or qualitative designs, limiting our understanding of the experience of Korean American cancer survivors over time. --- Implications for Practice Understanding and acknowledging the cultural background of Korean American cancer survivors is essential to improve their QOL. Based on the concept of Confucianism and filial piety, Korean American cancer survivors may not seek professional help to build social support, improve communication skills, or report feelings of depression or stress. Clinicians will need to pay closer attention to the quality of family communication as families prefer to resolve conflicts internally or they may try to avoid even talking about conflicts. Therefore, providing a safe environment for both cancer patients and their family caregivers to talk about health-related issues is important. It is also important for health professionals to understand that Korean Americans may prefer to make medical decisions as a family rather than leave these decisions to the patient only. The findings indicated that most of first generation Korean American cancer survivors will trust their clinicians and take their recommendations during decision-making, therefore, clinicians play a critical role in the decision-making process. Providing health information such as side effects of treatments, chemotherapy, healthy behaviors, post-surgery complications, and reconstructive surgery options in an easy to understand manner will help reduce cancer survivors' stress during the cancer experience and promote better QOL. Also, having an interpreter present during consultations may help cancer survivors to ask questions more freely without having to rely on their own interpreter to enhance making autonomous decision. Currently, the American Cancer Society has educational materials for various Asian or Pacific Islander languages that includes Korean. For Koreans, there are education materials related to: 1) cancer prevention and early detection, 2) side effects and treatment, 3) general knowledge of different types of cancer, 4) healthy behaviors, 5) caregiving, and 6) the patient-doctor relationship. Korean American cancer survivors respond positively when clinicians provide health informational brochures. Providing culturally-appropriate American Cancer Society educational materials that are culturally and language appropriate could further capitalize on their acceptance and prove to be very useful in informing both patients and caregivers. Most Korean Americans rely on their own ethnic community centers and churches for social support to extend their social networks and to access health services. Given this, clinicians or public health nurses may need to work with ethnic affiliated community-based organizations to provide culturally effective nursing interventions. Collaborating with Korean American community centers is critical since they have staff who can speak English, Korean, or both languages to help patients and caregivers. Since community centers may have already established good rapport and relationships with cancer survivors, providing education or support groups through community centers can provide a safe environment for cancer survivors to talk about their emotions or ask for help. For second-generation cancer survivors who prefer to join non-Korean American organizations, an organization like the Cancer Support Community can be a useful resource where they can receive psychosocial care at no cost. Finally, acknowledging the importance of providing culturally appropriate programs at nonprofit organizations is imperative. Western-oriented therapy or support groups focus on open communication, open discussions about conflicts, and emphasize individuals as compared to the family -all features of therapeutic approaches that are unfamiliar and more difficult for people from Asian cultures. Modifications of this form of therapy are needed to enhance the effectiveness of therapy or a support group for Korean Americans or other ethnic groups who follow Confucianism values. In summary, cancer is recognized as the leading cause of death for Korean Americans in the U.S.-a population that will increase in size over the coming decades. This review of the literature identified social support, communication, and acculturation as key factors related to the level of QOL in Korean American cancer survivors. These findings have implications for future research on Korean American cancer survivors, as well as for health care professionals who may provide care to this group. Ongoing efforts to infuse research and practice with culturally-relevant and sensitive interventions and therapeutic approaches, hold promise for ensuring that Korean American patients and their families receive high quality care that improves their quality of life. --- Consort diagram --- --- --- Variables Topics Findings Social support Family "I believe that cooperation and love from family and husband have helped me a lot" "Families don't understand. They say they understand, but they expect us to be the same people as before the disease" "My family expects me to work and function the same as before the surgery" "I have been devoted to my family…I just tolerate everything as many Korean women do" "Even after getting chemo, I still had to take care of my children, so that was hard" "My children are barriers for me" "I am sure the fear is the same, or even more because they don't have as much family support in this country, but we don't hear as much " Communication Healthcare system "I realized that doctors are very friendly. It's frustrating that I can't communicate with them well" "We, first-generation Korean Americans, prefer Korean speaking doctors because of the language barrier" "I had a few consultation sessions with a doctor before surgery… It was a little regretful because I did not get any detailed information" First vs. second generation communication "My mother is very emotional person… doesn't talk much… I think my thoughts become Americanized " Acculturation Living as immigrant "Most of immigrants have acculturative stress when they immigrate….I had stress from living together with my sister's family to save money" Language barrier "I felt stressed due to the language problem…. So I wonder if I would not have gotten cancer if I had stayed in Korea"

Problem Identification-There is limited understanding of Korean American cancer survivors' quality of life (QOL) within a cultural context. The study examined factors associated with the QOL of Korean American cancer survivors.

IntrODuCtIOn Doctors in training are important members of the clinical microsystems that deliver acute medical care. 1 The quality of that care is affected by the knowledge, attitudes and behaviours that they bring to bear. Despite long undergraduate and postgraduate training, many elements of real-world care can be under-represented in the formal curriculum, including broader patient-centred behaviours, such as expressing compassion, shared decision-making and providing good experience and practical skills such as managing oneself and one's work. 2 3 Once qualified, trainee doctors form communities of practice and continue to acquire skills and knowledge through 'on the job' contextual learning. [4][5][6] Learning from peers is an important and valued part of this experience. A national multispeciality survey of trainee doctors rated learning from other trainees as contributing more to their learning than lectures, tutorials and reading. 7 Knowledge of the patterns of peer-to-peer connections that channel such spread would enable quality improvement leaders and teachers to optimise uptake of new practice across clinical teams. 8 The aim of this research is to explore how knowledge, attitudes and behaviours diffuse between individuals through different network structures within bounded teams of trainee Open access doctors. Different types of skills and behaviours impact the quality of medical care. Clinical-technical knowledge and skills help trainees reach correct diagnoses, and deliver correct treatments . Patientcentredness skills increase the quality of patient and carer experience . We postulated a third category, that we termed 'organisation of work', by which we refer to the skills that allow clinicians to prioritise and order tasks, particularly non-patient facing tasks, so as to reduce the cost of care . We hypothesised that memes, relating to these different aspects of day-to-day work may be conducted via different channels within the same clinical team. 9 If this is the case, it may be necessary to use different approaches to disseminate memes associated with the different domains and this knowledge would serve as a guide to clinical leaders and quality improvement agents who aim to change practice across diffuse clinical teams. We conducted the research among several different teams of trainee doctors a single acute medical unit . The AMU provides care for the initial 24 to 72 hours of an emergency medical hospital admission. 10 11 AMU trainees have access to a relatively large team of colleagues who they can approach for advice, or who's work they can observe. We constrained the research to interactions that occur in real time during work and did not explore use of electronic media. The study used a mixed methods sequential design, with surveys mapping network structures, followed by interviews with members from later teams that added to and triangulated the survey data and explored survey findings. --- EthICAl ISSuES All participants gave informed consent. One researcher was a consultant who spent some time working in the unit. We believe that the relationship between PS and the trainees was not such that participants would feel coerced. All trainees invited took part, we believe this is because we ensured participation was convenient. The surveys asked people to name colleagues who were influential for them. We reassured participants that confidentiality would be maintained and survey data would be in anonymised format. --- MEthODS --- --- Surveys We invited all trainees in two consecutive AMU teams to complete an electronic survey . The sociometric survey included questions about who they had asked for advice, who they would choose to approach in future and who have they emulated or been influenced by in the AMU team. The questions were repeated for each of the three domains. Teams completed 19 and 20 surveys respectively. Survey responses were converted to unweighted directional edges and entered into SocNetV software to construct network graphs for each of the two teams, one graph for each work domain. Method of approach: Participants were invited at the end of routine team meetings to take part by accessing the survey on their electronic devices. --- Interviews Participants were selected as a maximum diversity sample, to include representatives at different stages of training to avoid bias. Subjects were approached on a 1:1 basis in the workplace and invited to do an interview at a time convenient to them. All those invited agreed to take part. Two researchers conducted interviews. GS, research fellow, had no prior contact with the teams; PS was a consultant physician and had had some intermittent working contact with the participants. Both had previous experience of qualitative research at postgraduate level. Coders agreed that there were no apparent differences between the findings from the interviews of the two researchers. PS as interviewer had preconception that highly influential individuals would be those with less patient-centred attitudes. These preconceptions relate to PS's own training in the 1980s. Results were very different from these views, and we believe that these preconceptions did not cause bias. GS is a non-clinical researcher and had no previous knowledge of acute medical practice. Interviews were semi-structured, and included vignettes to illustrate the meaning of the domains. Interview guides included questions about which colleagues were particularly influential, and what their characteristics were, in order to explore the finding of the presence of high influencers from the initial survey phase of the study. Interview guides are included as online supplementary file 3. We were not aware of any existing literature on knowledge transfer and influence specifically related to different aspects of practice. We used the domains as a framework to guide interviews, but used an inductive-deductive grounded theory approach to develop novel theories about the ways that diffusion happened and the way that influencers were identified. Developing theories were fed back in subsequent interviews for triangulation. 12 Theoretical analysis was done independently by two coders using NVivo V.11.4.1 . Coding was done after every two to four interviews. Themes that developed were incorporated as prompts into subsequent interviews. When items were coded differently the coders discussed these and reached consensus. Interviews continued until it appeared that theoretical saturation was achieved. Initial interview guides are appended. --- Open access --- Patient and public involvement None. --- rESultS --- Surveys We found that clinical-technical knowledge flowed through dense networks with rich horizontal connections, . In contrast, the network conducting memes relating to patient-centredness was sparse, and where there was person-to-person transmission, it tended to be among isolated pairs with no chains. Ways of organising work were apparently hardly influenced at all by others. For the clinical technical domain, the average number of people each individual influenced was 3.7 and 3.5 for team 1 and team 2, and the number of connections as a proportion of the maximum possible was 0.3 and 0.2. Equivalent values for the patient-centred domain were lower, 0.4 and 0.6 for average degree and 0.03 and 0.02 for density. Values for the communication of memes relating to organisation of work were 0.05 and 0.00 for average degree and 0.003 and 0.00 for density. Figures 123show the network graphs for the three domains for team one; the graphs for team two showed similar topography. Some individuals showed network features of high influencers. These were high degree centrality and betweeness centrality which is associated with the ability to control information flow. 13 --- Interviews We conducted 15 interviews and consider that theoretical saturation was achieved. Participants were representative of the mix of levels of seniority within the team of trainees: five foundation year , seven core or speciality trainees in year 1 to 2 , three core or speciality trainees in year 3 to 7 ; nine were female, all had trained in UK medical schools. Theories that emerged were; there were characteristics of actions that determined if they would be taken on board by a trainee, and there were characteristics of people that determined if their advice would be used or actions emulated; some values and beliefs that influenced behaviour came from outside of work; patterns of influencing differed between domains. There was consensus among trainees that a significant proportion of their work practice was based on learning from peers. You learn a lot of theory in med school but actually when you get here things are done differently and you learn by seeing what people more senior or experienced do. FY1 Domain 1: technical-clinical; diagnosing and treating Characteristics of influencers Chief determinants of individuals who were technical influencers were approachability and kindness, a record of visible successes and conscientiousness. --- Open access Approachability was based not only on the way an individual had responded in the past to requests for help and advice, but also on how kind they were in general -to patients and to members of other disciplines; trainees predicted that people who were globally kind would be kind to them if they sought advice. My feeling is their empathy toward patients will be similar to their empathy toward me There's definitely people who won't give you a hard time. You can see how they are toward other people, nurse, patients. CT1 Many participants expressed that they valued kindness toward patients for its own sake, and held kind colleagues in higher esteem, and were more likely to trust and copy their technical practices. I think, to be honest, the number one thing is kindness. CT1 Someone who's kind to patients and kind to everyone on the ward …… that's the kind of person I would copy in other ways. CT2 Conversely, Even if they're, say, a brilliant diagnostician or surgeon, if I see someone behaving badly with a patient, I struggle to learn from them. --- Trainees valued friendship and friendliness If they're pally, if you've chatted to them before, consider them friends, you're likely to trust their knowledge and skills. I'm much more likely to copy the good bits in the people I'm already on good terms with who might be my friend. Individuals who were seen as committed to doing their job well were influencers. Some work hard at being good at their job, you'll walk in on them, like, reading things online and things, that kind of person I would be more inclined to copy. CT2 There are certain doctors, I like the way they go about the profession, I feel I could learn a lot by acting like them. CT1 Characteristics of actions and behaviours themselves could make them more likely to be emulated. A great deal of weight was placed on observable success. This might be an unlikely disease picked up by a test, or a treatment when a patient is seen to recover. Strategies such as diagnostic workup were valued when 'thorough', meaning that several possible diagnoses were considered and excluded. When a colleague explained the logic behind a clinical approach, the trainees were more likely to incorporate it. Domain 2: providing good patient experience All trainees expressed that they had never, and did not envisage that they would in future, ask for advice on interpersonal interaction with a patient. There was a feeling that this was a behaviour that should be determined by one's own values that largely came from outside the profession and often predated medical school. I think you come with ideas of how you'd like to be, how you'd like to speak to people. You're taught a lot of science but you sort of come before that with an idea of how you want to provide people with dignity and being honest and open, that's the values I've had, it's been long-term. I had that sort of preconceived idea from before I even came to medical school. As a source of these values, parental influence was mentioned most often; trainees felt they carried the beliefs and behaviours that their parents displayed. Other cited sources were secondary school, social groups, exposure to life in general and, in only one case, religion. Probably from parents, encouraging good values, I was just always told that's the way to do it and eventually it becomes part of who you are. --- Characteristics of actions and behaviours When questioned about the ways that they could be influenced at work to behave differently toward patients, all trainees talked about communication skills and learning through observing ways that conversations were phrased. Trainees wanted to improve skills in 'set piece' situations, such as end-of-life discussion. They copied snippets, to use in the future. We explored what they meant by good communication that they would emulate. A commonly cited criterion was a successful outcome. Examples of success included the patient appearing to understand what they were being told, evidenced by verbal or non-verbal signals. A number cited as an example of success a patient being convinced to change their mind and accept a treatment that the doctor felt they should receive. In contrast to the clinical domain, personal characteristics of the person who was being observed was not perceived to impact on whether they would be influential. If I can see there's progress being made, personality is neither here or there, if goal has been achieved. FY2 Going beyond learning about phrasing, we explored the influencing of wider values and attitudes --- Characterisitics of people Many participants tended to select role models who had similar values, with the role model used to reinforce existing beliefs/behaviours. Open access I guess I come to it with a kind and caring nature and one of the important things I look for in a role model is, do they have that too? There is a subconscious… why did I get into this and who do I deem also to be in for the right reasons, actually to help people and look after patients. I guess, me, personally I've always been an all rounder, I see it's important I have respect for an all rounder like me, that's who I will look to; being kind is part of being an all rounder. Trainees particularly noticed small discretionary acts, cited examples included making tea for a patient, responding to a patient who is calling out for attention and making a special effort to contact a patient's relatives. Several felt that they had behaved differently after seeing somebody else put themselves out to provide good patient experience. If I see Dr X make someone a cup of tea I think I SHOULD try to be more like that, I SHOULD try to be better. Some trainees discussed the way that observing negative patient-centred behaviours could affect them, and felt their behaviour was adversely affected when the majority of a team were behaving in a non-patient centred way. However, they felt that they were more strongly influenced by seeing what they felt was good patient-centred care, than bad. When local culture was contrary to good care, they could be inspired for the good by a single individual. If someone said 'hang on a minute let's think about what more we can do for the patient', I think definitely I'd stop and take a moment and think 'is there more we can do'. FY1 Domain 3: organisation of work Trainees generally agreed that there were no personal characteristics that made an individual influential in terms of ways of organising work. There was a sense of willingness to do work differently if asked to do so but only by people who worked in the same clinical context and knew about how things worked. There was resistance to adapting practice in response to requests from people seen as outsiders, particularly managers. …if it's someone doing a similar job to you, I'd be inclined to try it, but if it was someone not from this environment, someone in a suit, someone who doesn't do a job like this, my reaction to that would be 'actually you don't understand how busy this job is'. FY2 If a senior ward nurse asked me to do something this way, because it helped them, I'd be more likely. There was a strong sense that an approach would have to be tested personally before adoption. If someone did something, and it seemed to work, I'd try it to see if it worked, it wouldn't matter whether I looked up to that person or not There was a widespread feeling that trainees could not make a difference to care by the way they organised their work because the system is so inflexible it tends to negate benefits of improving working practices, and so it is not worth trying to improve one's efficiency. --- DISCuSSIOn Behaviours and information flow from individual to individual. This leads to dissemination of knowledge and influence across groups through patterns of habitual connections that are termed social networks. This phenomenon has been described in a broad range of social contexts, including clinical teams. [14][15][16] Social network analysis explores the way that individuals interact with social context, and how structures emerge from interpersonal interactions, increasing our understanding of behaviours. Previous research has shown that social networks are key for developing practice among trainee doctors. [17][18][19] Knowledge about the function of networks among trainees offers important intelligence for those who aim to improve the quality of care within frontline clinical microsystems through training and influence. Most existing studies of health professionals have mapped generic social networks, without differentiating or identifying the type of information conducted. 20 In the teams of medical trainees that we investigated, we found that there were multiple synchronous network structures channelling memes relating to different domains of practice. This is the first study to our knowledge that has mapped coexisting networks that conduct different kinds of information within a single clinical team. We found that learning and influence in the different domains studied flowed very differently, if at all. Clinicaltechnical knowledge flowed through densely connected networks. In contrast, the networks relating patient centredness were present but were sparse, and there were suggestion from interviews that there were important influences outside the team and the profession. 'Organisation of work' appeared not to have any direct peerto-peer spread. This suggests different strategies might be needed to introduce memes relating to different domains. New clinical technical knowledge is the most likely to diffuse passively within a team. Patient-centred behaviours have a limited degree of peer-to-peer transfer, and so enthusiasts might best role model these behaviours frequently, to multiple members of a team. Organising work appears to be devoid of any spread or emulation, and human factor approaches might be more successful than role modelling. Interviews provided triangulation for the survey finding of the existence of a few high clinical-technical influencers. Attributes of clinical-technical influencers included consistent kindness, and signs of conscientiousness. An Open access interesting finding was that trainees appraised clinical management on the basis of visible diagnostic or therapeutic success. This is at odds with the fact that many diagnostic strategies deliberately aim for low yields, and many treatments have a high 'number needed to treat' or delayed outcomes: Therefore many correct management approaches have visible success only on rare occasions. This makes explanation of underlying logic important in teaching. In relation to the spread of patient centredness, trainees did not identify highly influential individuals, and it was actions themselves were seen as more or less worthy of emulation. Compassion, a concern for the impact of behaviours on the patients' internal psychological state was not volunteered as a driver. Instead, communication interactions were judged on the basis of 'getting the job done', for example, getting a message over accurately or getting the patient to agree with the doctor on a decision. The failure to talk about concern for the patient's emotions may be an artefact of the kind of language used day-to-day, and may not reflect an absence of compassion. However, the findings point to a need for leaders to be explicit about behaving to improve patient experience and to demonstrate and teach approaches such as shared decision-making. An interesting finding was that trainees described that they looked to people they felt to be similar to themselves as their role models. Doctors felt they carried their own values from outside their professional life, and looked for validation, rather than looking to adopt new sets of values. If true, this has impactions for those hoping to inculcate values among trainees, suggesting that amplification of existing attitudes may be more appropriate. Many of these findings are in keeping with existing literature. The presence of high influencers in healthcare teams is established. In keeping with our own results, the personality characteristics associated with this network influencing roles have been shown to include contentiousness and agreeableness. 21 The importance of perception of the utility of a practice, which we found to be key for adoption of ways of organising work, is also described elsewhere. 22 We have added an extra dimension to existing knowledge of healthcare professional networks by differentiating and describing social networks that spread different kinds of work-related information and influence in medical teams. This can inform teaching and communication strategies according to the domain of practice being targeted. Our findings also provide insight into how an individual might adapt their own behaviour so as to exert more influence. This work has a number of limitations. It was conducted in a single centre, and may not be representative of all acute settings, although in mitigation, six different consecutive clinical teams were included over a period of 2 years. We limited the research to trainee doctors, and did not include other professions; previous work has described the importance of networks that span professional groups; it would be interesting to go on to perform more inclusive studies. Future research could explore how individuals from outside of the core team and from different disciplines exert influence, and how electronic media provides wider peer-to-peer links. The categorisation of memes into three domains is pragmatic and probably over simplistc, and there are many more subtle aspects of practice that could be explored in future work. --- COnCluSIOn The social networks of influence and knowledge transfer among trainee doctors in an acute setting conform to quite different patterns when considering the spread of innovations in three domains, technical-clinical, patientcentred and organisation of work. The characteristics and prevalence of highly influential individuals also differs between domains. This casts light on the way that practices develop across a team, informs those who wish to enhance their influencing, and emphasises the importance of making desirable behaviours clearly visible to facilitate their spread. Knowing how these coexisting networks are configured and driven is likely to be useful for those leading quality improvement work that requires on the uptake of innovative behaviours across a clinical microsystem. This article presents independent research supported by the National Institute for Health Research under the Collaboration for Leadership in Applied Health Research and Care programme for North West London. The views expressed in this publication are those of the author and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care. Contributors PS conceived the study; PS and GS collected data; PS, GS, MH and IY all contributed to analysis and writing. --- Sullivan P, Saatchi G, Younis I, et al. Diffusion of knowledge and behaviours among trainee doctors in an acute medical unit and implications for quality improvement work: a mixed methods social network analysis. BMJ Open 2019;9:e027039. doi:10.1136/ bmjopen-2018-027039 ► Prepublication history and additional material for this paper are available online. To view these files, please visit the journal online . --- Data availability statement No data are available. --- Competing interests None declared. --- Patient consent for publication Not required. Ethics approval Ethical approval for this study was obtained from Hampshire-B REC; reference 15/SC/0052. Provenance and peer review Not commissioned; externally peer reviewed.

► This is the first research describing several coexisting social networks in the same team in medical practice. ► Interviews were used to explore and explain phenomena underlying the social network patterns. ► The surveys and interviews could be subject to recall bias, which is a recognised issue in social network research. ► Respondents may be subject to influence and learning that they are not conscious of, and so an 'invisible' social network may have been overlooked. ► We researched social networks within bounded teams of trainee doctors; links to other doctors outside the core team and links to other disciplines are not included.

Background The policy response to the COVID-19 pandemic has greatly impacted the delivery of primary care in the United Kingdom . On 5 March 2020, primary care providers were recommended to change face-to-face consultations to triage appointments via telephone or video to reduce the risk of infection in practices [1]. Older and vulnerable people were advised to shield at home and primary care providers asked to roll out remote consultations to this group as a priority [2]. The first UK national lockdown was announced 23 March 2020, requiring the public to only leave their homes for limited reasons including food shopping and medical needs [3]. Primary care plays a crucial role in caring for individuals with multimorbidity [4,5]. This group has increased healthcare needs and a higher risk of severe COVID-19 compared to those without multimorbidity [6][7][8][9]. The presence of some long-term conditions , including hypertension, diabetes and coronary heart disease [10,11], has been identified as a COVID-19 risk factor, along with sociodemographic characteristics such as being male [12], socially deprived [9], and from ethnic minority groups. Individuals of ethnicity other than White experienced a higher rate of COVID-19 mortality, in particular those from Black or Asian ethnic groups [9,12,13]. These risk factors, alongside new barriers to accessing primary care, may have changed healthcare needs and utilisation during the pandemic. Previous research suggests that ethnicity is an independent contributor to multimorbidity, even after adjusting for social deprivation [14]. The prevalence of multimorbidity varies across ethnic groups and distinct patterns of disease accumulation are observed over time. For example, individuals of Black ethnicity have a higher prevalence of multimorbidity, different patterns of LTC combinations and a more fluctuating disease accumulation pathway compared with those of White ethnicity [15,16]. Individuals with multimorbidity and particular ethnic groups fared worse during the COVID-19 pandemic, with an increased risk of adverse outcomes due to COVID-19 [9,12,13]. However, little is known about how the pandemic affected their use of primary care services. Existing evidence on overall population trends indicates that there was an initial reduction in consultations in April 2020 and face-to-face consultations fell substantially, while telephone and electronic delivery increased [17][18][19], but whether changes were magnified among those with multimorbidity and from ethnic minority groups remains unexplored. This paper aims to assess the impact of the response to the COVID-19 pandemic on primary care consultations of individuals with multimorbidity, and identify whether the effects vary by ethnic group. Recognising population subgroups with differential impacts from the pandemic may inform care prioritisation and preparedness for future pandemics to contain the widening of health inequalities. --- Methods --- Study design and population A longitudinal study design, based on monthly data from primary care health records in the Lambeth DataNet, is used. Lambeth is an inner-city borough in south London which contains an urban, deprived, and multi-ethnic population. The sample includes all patients aged ≥ 18 years who were registered to a general practice in Lambeth between the 38-month period from February 2018 to March 2021. The 'pre-pandemic' period is defined as February 2018 to February 2020 and the 'pandemic' period as March 2020 to March 2021 . Data was not available past March 2021. March 2020 is considered the start of the pandemic reflecting when the UK healthcare system's response began and the first national lockdown was implemented [1,3]. --- Statistical analysis Descriptive analyses are conducted for the total monthly consultation rate per 1000 registered patients. This is categorised by provider type and delivery mode to identify changes in the way primary care was provided, and then by multimorbidity status . The effect of the pandemic on primary care consultations is assessed using an interrupted time series analysis [20,21]. The analysis is conducted via a generalised linear model, with a negative binomial distribution and a log-link to account for overdispersion in the number of primary care consultations. Interaction terms to consider both a change in level and slope from the onset of the pandemic in March 2020 are included. The dependent variable is total primary care consultations, with patient-month as the unit of analysis. Total consultations are comprised of three provider types , nurse and other healthcare professionals) and four modes of delivery . Electronic consultations refer to e-mails and other remote online consultations . Administrative consultations are included in descriptive analyses but excluded from models as they may capture contacts that do not reflect healthcare needs. The first model specification predicts the effect of the pandemic on total monthly consultations, and analyses whether there are inequalities between those with multimorbidity and those without multimorbidity. Multimorbidity is defined as having two or more of 32 LTCs, selected to reflect demographic and morbidity patterns in an inner-city context [22] . The model includes interaction terms between a multimorbidity indicator variable and the pandemic level and slope change variables to assess differences against those without multimorbidity. Time is the number of months elapsed since the start of the study and captures the linear trend, and Pandemic is a dummy variable indicating the pre-COVID-19 period or during the COVID-19 period . GP practice includes a set of dummy variables to account for potential clustering or similarities in consultation rates of patients within the same practice, caused by for example, differences in the size of the workforce and access to technology for remote consultations [23]. Monthly dummy variables were included to adjust for seasonality. LagRes is the lagged residuals. Inspection of the autocorrelation and partial autocorrelation functions identified autocorrelation in the dependent variable. To adjust for this, the model was first run without LagRes. The residuals from this model were extracted and lagged, and then added as an explanatory variable for the main model. Estimates are given as incidence rate ratios . The second model focusses on the multimorbid population and analyses the variability of the COVID-19 impact by ethnic group. This model has the same specification as Eq. 1, except the multimorbidity indicator is replaced with ethnic group. Classification of ethnicity is based on the 2011 Census and includes seven categories: White, Black , Asian , Mixed ethnic group, Other ethnic group, Unknown and 'Missing' . Individuals with missing ethnicity data are often at higher risk of worse health outcomes [24]. A further characterisation of the 'Missing' ethnic group category was attempted; however, other variables were also unavailable for this group which limited analysis, for example main language was only recorded for 15% . To test for heterogeneity within the main ethnic groups, the model was Consultations it = 0 + 1 Time + Lastly, the ethnicity model is also estimated separately for each delivery mode to assess whether the shift towards telephone and remote consultations is associated with inequalities by ethnic group. Results are presented only for face-to-face consultations and telephone consultations as they comprise 98.5% of total consultations. A strength of using an ITS model design is that it controls for differences in the consultation rate and trend that may already have existed between the groups prepandemic, and therefore the models do not require controls for time-invariant covariates. However, it assumes no changes in the characteristics of the underlying population that could explain observed differences in consultation rates over the study period. The number of individuals registered to a practice declined by 4% between February and December 2020. Temporal trends in the sociodemographic characteristics of the population were investigated. No significant changes were found, indicating that covariate adjustments were not needed . As sensitivity analyses, first the ethnicity models also controlled for age to assess if variations by ethnic group were being confounded by potential differences in age distribution, since age was a major driver of care prioritisation during the pandemic. Second, the multimorbidity model was calibrated for individuals with complex multimorbidity compared with individuals with only two LTCs. This analysis aimed to explore how results may differ within the heterogeneous multimorbid population. All analyses were conducted using R version 4.1.2. --- Results --- Descriptives The sample consisted of 460,084 individuals , of whom 24% had multimorbidity. The percentage under the age of 40 years was 55%, 32% were between 40 and 59, 11% between 60 and 79, and 2% were 80 years or over. The mean age was 41 years , and half of the sample were female . For ethnic group, 56% stated they were of White ethnicity , 18% Black/African/Caribbean/Black British, 7% Asian/Asian British, 5% Mixed/ multiple ethnic groups, 3% Other, and 2% Unknown. Ethnicity data was missing for 8% of the sample. English was considered the main language for 57% of the sample, and 64% lived in socially deprived areas . The spread of observations was relatively stable across the study period, with 2.6-2.7% of observations in each month. Further characteristics by ethnic group within the multimorbidity population are presented in Additional file 4: Table S1. Table 1 presents changes in consultation rates by provider type and delivery mode for 4 months in the sample period: February 2018 , February 2020 , April 2020 and March 2021 . In the full population, total primary care consultations per 1000 patients fell by 25% in April 2020 when compared to the previous month . The consultation rate experienced an upward trend after April 2020 and there was a 46% growth in March 2021 compared to February 2020 . The mean monthly consultation rate in the pre-pandemic period was 374 per 1000 patients , compared to 436 in the pandemic period , 17% higher. The standard deviation of consultation rates is relatively large as monthly data has more variability and skewness than annual data. In February 2020, face-to-face consultations made up 75% of total consultations, while 24% were telephone. In April 2020, telephone became the most frequent method , while face-to-face dropped to 38%. The shift towards remote consultations was less persistent for nurses, for example in March 2021, 82% of nurse consultations were faceto-face, while it was 45% for GPs and 63% for other healthcare professionals. There were small shifts in the composition of the healthcare providers towards the end of the pandemic period, with the proportion of consultations delivered by nurses decreasing and the proportion by other healthcare professionals increasing. For example, in February 2020, nurses represented 14% and other healthcare professionals represented 17%, but in March 2021 the proportions were 10% and 21% respectively. Within the multimorbid population, total primary care consultations per 1000 patients fell by 18% in April 2020 when compared to the previous month . The consultation rate experienced an upward trend after April 2020 and there was a 40% growth in --- Main results In the initial months of the pandemic, overall consultation rates as predicted by the ITS model were lower than expected . For example, in March 2020 the rates were 10% lower than the counterfactual . Faster growth in the latter half of the pandemic resulted in consultations then being higher than the counterfactual, for example in March 2021 the rate was 25% higher than what would have occurred without the pandemic . Individuals with multimorbidity had 3.6 times the rate of consultations compared to those without multimorbidity in the pre-pandemic period . The pre-pandemic trend was slightly steeper for those with multimorbidity . During the pandemic, the gap between the two groups grew, with those without multimorbidity experiencing a larger initial fall in primary care consultations from 223 consultations per 1000 patients in February 2020 to 208 in March 2020, a 7% fall. The rate remained unchanged for those with multimorbidity to 882 , <1% change). Between March 2020 and July 2020, the consultation rate for those with multimorbidity remained over 4 times the rate of those without multimorbidity. For example, in March 2020, the rates were 882 and 208 consultations per 1000 patients, respectively for each group. Those without multimorbidity then experienced a faster rate of increase in consultations and by March 2021, the differences had reduced to 3.8 times; 1269 and 335 consultations . Similar patterns were found when comparing those with complex multimorbidity to those with only two LTCs, with a smaller contraction in primary care Fig. 1 Results of ITS analysis-primary care consultation rates and counterfactual scenario , using full population consultations for those with complex multimorbidity . Within the multimorbid population, individuals of Asian ethnicity had the highest total consultation rate in the pre-pandemic period , followed by people of Black , Other , Mixed , White and Unknown , then Missing ethnicities . The clinical drivers of the differences in baseline consultation rates vary by ethnic group. For example, in the dataset, individuals of White ethnicity have a higher rate of anxiety and depression than those of Black ethnicity, while individuals of Black ethnicity experience a higher rate of chronic pain, hypertension and diabetes. The average number of LTCs is slightly higher among people with Black backgrounds; 3.39 compared to 3.15 for those of Mixed ethnicity for example . There were minor differences in pre-pandemic trends, with individuals of Black ethnicity having a slower growth rate in consultations than White ethnicity, while the group with Missing ethnicity had a faster growth rate . Comparing the consultation rates for each ethnicity to the model baseline , between March 2020 and June 2020 the relative rate for those of Black, Asian, Other and Missing ethnic groups decreased slightly compared to White. For example, for individuals with ethnicity Missing, the consultation rate dropped from 577 per 1000 patients in February 2020 to 554 in March 2020 . The rate for people from Asian backgrounds remained a similar proportion to those of White for the rest of the pandemic period, while the rate for the Black, Mixed, Other, Unknown and Missing ethnic groups began growing at faster rates. The highest increase in relative rate was for those of Unknown ethnicity. Between February 2020 and March 2021, the relative rate for people with Unknown ethnicity compared to White went from 0.93 to 1.04; a growth from 704 consultations per 1000 patients to 1064 . For those of Mixed and Unknown ethnicities, the relative rate compared to White was higher than the February 2020 baseline throughout the pandemic period. The main results held when models adjusted for age , while suggesting the consultation rate for people of Mixed ethnicity may be slightly underestimated. There were also inequalities in the change of face-toface consultations . For people of Black, Asian and Other ethnicities, the consultation rate fell more relative to White. For example, in April 2020, for individuals of Black ethnicity, the relative rate went from 1.23 times the rate of White ethnicity to 1.19 times consultations per 1000 patients to 355 ). For people from Asian backgrounds, the comparable figures were from a rate of 1.26 times to 1.16, and for individuals in the Other ethnicity group it was 1.15 to 1.11. The relative rate began to recover for those of Black and Other ethnicities around December 2020, while the rate remained comparatively low for people of Asian ethnicity. The rate for individuals of Mixed ethnicity was similar to White until around July 2020, when the relative rate became higher for those of Mixed ethnicity. For individuals with Unknown ethnicity, the relative rate remained above the February 2020 baseline throughout. For telephone consultations, the rate for individuals of Black, Asian and Other ethnicities increased more than the rate of White . For example, people from Asian backgrounds had a relative rate compared to White of 0.95 in February 2020 , but increased to 1.21 in March 2020 . During the pandemic period the relative --- Table 2 Results of ITS analysis-effect of the pandemic on primary care consultations by multimorbidity status Estimates are expressed as the consultation rate per 1000 patients, with the 95% confidence interval in parentheses a The relative rate is the consultation rate of individuals with multimorbidity divided by the consultation rate of the model baseline . Number of observations was 12,847,347, after the removal of 1.7% of data points that were identified as outliers (>3. 5 rate ranged from 1.15 to 1.21 for this group. For those of Black ethnicity, the baseline was 0.99 in February, and it then ranged from 1.15 to 1.20 during the pandemic period, and for individuals in the Other ethnicity group, it was a baseline of 0.93 and ranged from 1.02 to 1.12. Individuals of Mixed, Unknown and Missing ethnicity categories experienced a rate quite similar to those of White ethnicity, with some increasing slightly more than White towards the end of 2020. Additional figures for the ITS results can be found in Additional file 8: Figs. S1-S3. --- Heterogeneity within ethnic group In general, there were no significant differences within each of the five overarching ethnic groups using the more comprehensive 18 ethnic group classification. Four exceptions were noted; individuals of 'Other Black' within the Black ethnic group, individuals of 'Other White' within the White ethnic group, individuals of Chinese ethnicity within the Asian ethnic group, and ' Any Other' in the Other ethnic group had a slightly distinct effect compared to other individuals within their respective ethnic group . --- Discussion --- Summary This paper documented inequalities in the response to the COVID-19 pandemic on primary care consultations for individuals with multimorbidity. There was an initial decrease in the consultation rate in April 2020, which may be due to patients being deterred from contacting their practices over fears of infection and not wanting to put extra strain on the healthcare system, or patients using alternative services such as NHS 111 and secondary care. Practices may also had reduced capacity amid the initial transition period. Telephone calls were used much more frequently in the pandemic period as primary care providers reduced face-to-face contact in line with NHS England's recommendation [1]. The initial contraction in consultation rates was smaller for the multimorbid population compared to those without multimorbidity, suggesting that there may have been a successful needs-based prioritisation of multimorbidity at the start of the pandemic. Older people, who have a higher rate of multimorbidity, and those with certain LTCs were classified as 'vulnerable' [2]. Patients with the highest risk in this group were actively contacted by the NHS [2] and may have felt more comfortable approaching their practices regularly. After the initial contraction, Fig. 2 Results of ITS analysis-primary care consultation rates in the multimorbid population, by ethnic group. Notes: For similar figures, but with face-to-face consultations and telephone consultations, please see Supplement 5 consultations grew at a faster rate compared to pre-pandemic, likely due to an increase in healthcare need from COVID-19 and deferred appointments from the start of the pandemic. The large increases in consultations from January 2021 may also be partly attributed to the rollout of the vaccination programme, which commenced in England in December 2020 [25]. In Lambeth specifically, a surge testing that started in February 2021 due to a new COVID-19 variant may partially explain the increase in recorded consultations [26]. Inequalities in the impact of COVID-19 by ethnic group within the multimorbid population were also identified. The pandemic immediately impacted individuals of ethnic minority groups slightly more than those of White ethnicity. However, the primary care consultation rates for people from these ethnic backgrounds recovered quickly, with the exception of individuals of Asian ethnicity. The differences in growth rate meant that while the rate for people of Asian ethnicity had the highest primary care utilisation in the multimorbid population pre-pandemic, utilisation rates for individuals of Black ethnicity became the highest in the pandemic period. The inequalities by delivery mode were stronger, with those of Black, Asian and Other ethnic groups switching from face-toface to telephone consultations at a higher rate. --- Comparison to existing literature Previous literature has not reported inequalities in the impact of the pandemic on healthcare utilisation by multimorbidity status and ethnic group, yet some similarities are observed in the overall trends in primary care consultations during the pandemic. An initial contraction in consultations at the start of the pandemic and large shift towards remote delivery is well-documented in the literature [17][18][19]. Using data from 21 general practices in Bristol, North Somerset and South Gloucestershire Clinical Commissioning Group, Murphy et al. [18] reported a decline in consultations by 17% in April 2020 compared to April 2019 and that 90% and 46% of consultations delivered by GPs and nurses, respectively, were remote. The fall in overall consultations was similar in this study , as was the percentage of remote nurse consultations , yet fewer GP consultations were delivered remotely . The GP practices in our sample may have faced more difficulties in adapting to remote delivery in April 2020. Based on a longer time horizon , Watt et al. [19] found that remote primary care consultations represented 50-60% of all consultations using data from Clinical Practice Research Datalink, similar to this paper's findings of 54%. Existing literature shows that individuals of Black and Asian ethnicities were at a higher risk of severe COVID-19 [9,12,13]. This could have two conflicting effects on primary care consultations; to increase primary care utilisation if more healthcare is required, or decrease consultations if the severity of the disease requires hospitalisation rather than primary health care. It is possible the slightly larger initial contraction for individuals of Black ethnicity at the start of the pandemic was partially a result of higher hospitalisation rates from COVID-19, and that the higher growth in consultation rates reflects primary care dealing with a larger COVID-19 and 'long-COVID' burden in this population [12,13]. Analysis of secondary care data during the pandemic is needed to provide further insight into these hypotheses. A similar increase in healthcare use for individuals of Asian ethnicity was not observed, despite this higher risk of COVID-19 for this group. Inequalities in the impact of the COVID-19 response for ethnic minority groups in the UK have been attributed to a range of complex factors, including being poorer, having less suitable housing, type of employment and barriers in access to health services [27]. A shift towards remote consultations may also have increased barriers to access for particular groups, including those who lack access to the appropriate technology, those who cannot afford telephone bills or good quality broadband, those who lack private space in their household, those who rely on non-verbal communication, and individuals with low English skills [28,29]. The larger proportional fall in face-to-face consultations for people with an Asian background may be due to multigenerational, overcrowded households living with someone over the age of 70 and older being more common for individuals of Bangladeshi and Pakistani ethnicity [30]. Having a 'vulnerable' person in the household may have deterred these individuals from attending face-to-face consultations. Individuals from Bangladeshi and Pakistani backgrounds are also more likely to have dependent children which may have impeded access to in-person care when school facilities were closed [31]. Face-to-face consultations are typically superior at gathering more patient information, with longer durations and better relationship building compared to telephone and remote consultations [32][33][34]. A disproportionate reduction in face-to-face consultations may negatively impact the quality of care received by individuals of Asian ethnicity with multimorbidity. These findings complement current literature on healthcare disruption. Disproportionate impacts of healthcare disruption on health service use and outcomes have been identified among groups defined by age, ethnicity, social deprivation, LTCs and migrant status [35][36][37][38][39][40]. For example, consequences tend to be magnified among ethnic minority groups [35][36][37]. Individuals of Black, Mixed and Other ethnicity experienced lower non-COVID-19 hospital use during the lockdown in England, which may indicate a higher risk of unmet healthcare need [35]. This paper finds similar patterns of disruption by ethnic group for primary care utilisation. While there is evidence that the disruption varies by single LTC, none of the previous literature has focused on individuals with multiple LTCs [38]. The variation in disruption by LTC can also help explain some of the ethnic disparities in utilisation, as the clinical drivers for healthcare needs vary by ethnic group. For example, reduction in primary care contacts was largest for diabetic emergencies, which is more prevalent among ethnic minority groups. Understanding the most common barriers in access to care among ethnic groups is needed to device interventions aimed at reducing inequalities in primary care use and quality. Tailoring and prioritising disease management in a culturally sensitive manner is key to increase trust and promote better relationship building. --- Strengths and limitations This study expands existing literature looking at the healthcare inequalities associated with the pandemic, focusing on the growing multimorbid population. A large, longitudinal dataset with rich clinical and sociodemographic information was used and the data characterises an urban, deprived, and multi-ethnic borough in London. Ethnic groups overrepresented in this sample were disproportionately affected by the pandemic and the available data on ethnicity allowed for an assessment of related inequalities. Data on ethnicity are often missing in health records impeding inequality analysis [41][42][43][44], for example ethnicity was recorded for 78% of patients registered between 2006 and 2012 to the Clinical Practice Research Datalink, up from 27% for those registered 1990-2012 [44]. In contrast, ethnicity data was only missing for 4% of patients in this study's model by ethnic group. However, this paper only characterised ethnic inequalities in primary care consultations within, but not between, GP practices due to the inclusion of GP practice fixed effects. Further research should also test for the existence of ethnic inequalities between GP practices. Healthcare utilisation was measured using primary care consultations only and pandemic impacts on secondary care use were not made accessible for this population. This is an important consideration as ethnicity is a risk factor for the severity of COVID-19 symptoms, which will influence whether a patient requires primary or secondary care. The reported increase in total consultations may be a result of telephone consultations being used to assess if an in-person consultation is required, causing a degree of duplication and may overestimate the true healthcare demand. The duration of and rationale for the consultations were not available to understand the extent of this and to evaluate whether differences in the pace of growth between ethnicities reflect changes in actual need or inequalities in accessing care. Misclassification errors in the delivery mode of primary care consultations are possible, particularly for electronic consultations which are more recent and may be harder to identify. However, electronic consultations represent a very small proportion of total primary care consultations. Differences in the vaccine uptake between ethnic groups [45] may also affect variations in healthcare need after the vaccination programme was rolled out in December 2020. However, vaccination status of the patients was not available in the dataset. Multimorbidity was denoted as a binary variable, defined as those with two or more long-term conditions. Sensitivity analyses comparing individuals with complex multimorbidity to those with only two LTCs provided preliminary insights into possible differential pandemic effects within the multimorbid group. The smaller reduction in primary care consultations among the complex multimorbid may suggest that clinical care for this group was particularly prioritised during the pandemic. Further research by counts of LTCs or the most common LTC clusters could reveal more information about pandemic impact and recovery among those with the greatest severity of health concerns. This paper benefited from a high proportion of ethnic minority groups in the data, which allowed for more granular analyses of these groups. However, results may be less generalisable to the wider population. The study population is also younger than the national average, with only 9% aged 65 or over, compared to 19% for England [46]. However, these demographics are typical of many inner-city communities [47]. Lastly, as an ITS approach is quasi-experimental, it has limitations in assigning causality to the pandemic and it is possible that factors not captured by the model influenced the observed trends. --- Conclusions Primary care utilisation of individuals with multimorbidity was significantly affected by the COVID-19 pandemic. While there is evidence of a successful needs-based prioritisation of multimorbidity patients within primary care at the start of the pandemic, inequalities among ethnic minority groups were found. Understanding inequalities generated by the response to the COVID-19 pandemic is essential to identify those who may have under-used primary care. These inequalities may increase their risk of future health complications if their conditions were less frequently monitored or new diagnoses delayed. Further research into the consequences of possible late or missed diagnosis during the pandemic, in particular for the disadvantaged groups identified in this paper, should be considered. As this study explores primary care consultations only, future work is required into secondary and tertiary care usage to identify a more holistic view of the effect of the COVID-19 pandemic on healthcare utilisation of individuals with multimorbidity. --- Table 4 Results of ITS analysis-face-to-face and telephone consultations per 1000 patients by ethnicity Estimates are expressed as the consultation rate per 1000 patients, with the 95% confidence interval in parentheses a The relative rate is the consultation rate divided by the consultation rate of the model baseline . For the face-to-face model, 1.3% of data points were removed after being identified as outliers . For telephone, 1.4% were removed. Number of observations was 3,157,225 for the face-to-face model and --- --- Additional file 5: Parameter estimates from the ITS models. Table S1. Results of ITS analysis -Effect of pandemic on primary care consultations by multimorbidity status. Table S2. Results of ITS analysis -Effect of pandemic on total primary care consultations within multimorbid population, by ethnicity. Table S3. Results of ITS analysis -Effect of pandemic on face-to-face and telephone consultations within multimorbid population, by ethnicity. --- Additional file 6: Results of ITS analysis -Effect of the pandemic on primary care consultations by complex multimorbidity status . Table S1. Results of ITS analysis -Effect of pandemic on total consultations, by complex multimorbidity status. Table S2. Results of ITS analysis -Effect of pandemic on total consultations, by complex multimorbidity status. Additional file 7: Table S1 ]. The funder did not contribute to the design of the study, the collection, analysis, and interpretation of data or the writing of the manuscript. --- --- --- --- Competing interests The authors declare that they have no competing interests. • fast, convenient online submission • thorough peer review by experienced researchers in your field • rapid publication on acceptance • support for research data, including large and complex data types • gold Open Access which fosters wider collaboration and increased citations maximum visibility for your research: over 100M website views per year --- • At BMC, research is always in progress. --- Learn more biomedcentral.com/submissions Ready to submit your research Ready to submit your research ? Choose BMC and benefit from: ? Choose BMC and benefit from: ---

Background The COVID-19 pandemic caused rapid changes in primary care delivery in the UK, with concerns that certain groups of the population may have faced increased barriers to access. This study assesses the impact of the response to the COVID-19 pandemic on primary care consultations for individuals with multimorbidity and identifies ethnic inequalities. Methods A longitudinal study based on monthly data from primary care health records of 460,084 patients aged ≥18 years from 41 GP practices in South London, from February 2018 to March 2021. Descriptive analysis and interrupted time series (ITS) models were used to analyse the effect of the pandemic on primary care consultations for people with multimorbidity and to identify if the effect varied by ethnic groups and consultation type.Individuals with multimorbidity experienced a smaller initial fall in trend at the start of the pandemic. Their primary care consultation rates remained stable (879 (95% CI 869-890) per 1000 patients in February to 882 (870-894) March 2020), compared with a 7% decline among people without multimorbidity (223 consultations (95% CI 221-226) to 208 (205-210)). The gap in consultations between the two groups reduced after July 2020. The effect among individuals with multimorbidity varied by ethnic group. Ethnic minority groups experienced a slightly larger fall at the start of the pandemic. Individuals of Black, Asian, and Other ethnic backgrounds also switched from face-to-face to telephone at a higher rate than other ethnic groups. The largest fall in face-to-face consultations was observed among people from Asian backgrounds (their consultation rates declined from 676 (659-693) in February to 348 (338-359) in April 2020), which may have disproportionately affected their quality of care.The COVID-19 pandemic significantly affected primary care utilisation in patients with multimorbidity. While there is evidence of a successful needs-based prioritisation of multimorbidity patients within primary care at the start of the pandemic, inequalities among ethnic minority groups were found. Strengthening disease management for these groups may be necessary to control widening inequalities in future health outcomes.

Scientific editors shape the content of academic journals and set standards for their fields. Yet, the degree to which the gender makeup of editors reflects that of scientists, and the rate at which editors publish in their own journals, are not entirely understood. Here, we use algorithmic tools to infer the gender of 81,000 editors serving more than 1,000 journals and 15 disciplines over five decades. Only 26% of authors in our dataset are women, and we find even fewer women among editors and editors-in-chief . Career length explains the gender gap among editors, but not editors-in-chief. Moreover, by analysing the publication records of 20,000 editors, we find that 12% publish at least one-fifth, and 6% publish at least one-third, of their papers in the journal they edit. Editors-in-chief tend to self-publish at a higher rate. Finally, compared with women, men have a higher increase in the rate at which they publish in a journal soon after becoming its editor. A recurring theme in the study of science is the accumulative advantage that elites enjoy in academia, be it highly cited scientists 1,2 , prestigious institutions 3 or influential countries 4 . Elites reinforce their status via scientific publications 1,5 , and editors play a key role in this process by having the final say about what gets published 6,7 , thereby controlling the channel through which scientists receive prestige and recognition 8 . Moreover, editors themselves are scientific elites, who have gained recognition from their community as experts in their fields 9,10 . Therefore, characterizing the appointment and publication patterns of editors is key to understanding scientific elites. Unfortunately, not all scientists have an equal chance of becoming editors. Women, historically marginalized in academia, face additional barriers in attaining scientific opportunities in general [11][12][13][14] , and elite status in particular [15][16][17][18][19] . In this vein, there has been widespread, yet fragmented, evidence showing that women are underrepresented on editorial boards [20][21][22][23][24][25][26][27][28] . Gender diversity on editorial boards is not only important in its own right 29 , but also has broader implications. An inclusive editorial board signals that the journal is open to all authors 30 , implying that the underrepresentation of female editors may create a vicious cycle that further deters women from participating in science 29 . While being the gatekeepers of science, editors also actively seek opportunities to publish. Although some editors are full-time professionals , the vast majority of editors are research-active academics, who perform editorial duties in addition to being a scientist. Such editors would benefit from publishing original research articles, as the evaluation of academics heavily relies on bibliometric outcomes 1,31 . Sometimes editors publish their findings in the journals they edit [32][33][34][35][36][37][38] , occasionally resulting in controversies [39][40][41][42] . Such controversies are fuelled by the possibility that the editors' submissions are treated favourably, which may be considered as 'an abuse of the scientific publishing system' 41,42 . Both the self-publishing behaviour of editors and the underrepresentation of women have received widespread attention in different disciplines; see Supplementary Tables 1 and2 for a summary of this literature. Nevertheless, key aspects remain missing due to the lack of a longitudinal dataset that spans multiple disciplines. In particular, none Article https://doi.org/10.1038/s41562-022-01498-1 count, h-index, collaborator count and affiliation rank. Note that the attributes of the editor are measured before their editorship starts, implying that the measurements are not influenced by the potential boost in visibility associated with being an editor. Moreover, the scientist being compared with the editor has their attributes measured in the same year, implying that the pair had the same career length when the measurements were taken. Finally, it should be noted that those scientists may themselves include editors of different publishing houses, as would be expected from the average scientist in MAG whom those scientists are meant to represent. If editors are scientific elites, we would expect their bibliometric outcomes to be much higher than that of average scientists. Indeed, compared with an average scientist of the same academic age and in the same discipline, an editor tends to have seven times more papers , eight times more citations and four times greater h-index ; see Fig. 1a-c. Note that these results disregard editorials; see Methods for more details on how editorials were identified. As for the number of collaborators, an editor has on average 163 at the start of the editorship, while the average scientist has about 29 . In terms of affiliation, 35% of editors are affiliated with a top-ranked institution-one that is ranked among the top 100 according to the Academic Ranking of World Universities 56 -compared with just 20% for scientists . Supplementary Fig. 1 shows the distribution of the data in Fig. 1a-d, while Supplementary Figs. 23456show a breakdown of Fig. 1a-e over disciplines. Moreover, instead of sampling a single scientist per editor, we sample 50 and 200 with replacement, and find broadly similar trends . Next, we analyse how the characteristics of editors upon the start of their editorship have changed over the past four decades. Specifically, let denote an editor-journal pair such that editor e served on journal j. Moreover, let year 1 be the first year of the editorship, and let year 0 be the year that precedes it. Then, for any given year y ∈ [1980, 2017], we consider every e,j such that year 0 = y, and measure the characteristics of e and their matched scientists at the year y. The results are depicted in Fig. 1f-k. As can be seen, the expected number of citations that an editor has accumulated by the start of their editorship has increased almost tenfold over the past decades , the number of accumulated papers has more than quadrupled , the h-index has tripled , the number of collaborators has increased more than sixfold , while the percentage of those affiliated with top-ranked institutions has decreased . Next, we examine the gap between editors and scientists over the past decades. Comparing 1980 with 2017, we find that the gap in productivity has increased almost fivefold , the gap in impact has increased more than ninefold , the gap in h-index has more than tripled , while the gap in collaborator count has increased more than sixfold . As for the percentage of those affiliated with a top-ranked institution, it has decreased over the years for both editors and scientists at about the same rate , suggesting that this trend is not related to changes in the way editors are recruited, but rather to changes in the global demographics in academia. Again, these results remain unchanged when sampling 50 and 200 scientists per editor. Finally, looking at the academic age of the editors upon the start of their editorship, we find that it has increased from 15 years in 1980 to about 20 years in 2017 . These findings suggest that, when it comes to assuming an editorial role, being impactful, productive, connected and experienced seem to matter more than being affiliated with a top-ranked institution. This seems to persist even when excluding Biology-the discipline with the highest h-indices, citation count, collaborator count and editor countas shown in Supplementary Fig. 9. Note that in Fig. 1f-k an anomaly can be seen around the years 1998-2003. Upon enquiry, Elsevier of the studies compare the gender gap and self-publishing behaviour across disciplines, as they only focus on one discipline each. The only exceptions are the work of Mauleón et al. 10 and Bošnjak et al. 34 , but their analyses are restricted to Spanish and Croatian journals, respectively. Another limitation in the literature is the lack of comparison between editors and other research-active scientists, with the exception of Mauleón et al. 10 , whose analysis is restricted to Spanish journals only. Such a comparison is critical, as it provides a discipline-specific, and year-specific, benchmark against which gender disparity and editor self-publishing can be measured. In addition to the comparison between editors and research-active scientists, other comparisons can be informative when analysing the self-publishing behaviour of editors. First, by comparing editors with their colleagues-those who serve on the same editorial board-one would account for the culture of the journal in question, thereby detecting editors whose publication rate is high relative to the norm in that journal. Second, by comparing the publication patterns of the editors before and after the start of their editorship, one might detect whether there is a notable difference in the number of papers they publish in their journal right after assuming their editorial role. Third, by comparing female with male editors, one might determine whether there are marked gender differences in self-publication rates. These critical comparisons are absent from the literature, except for the works of Campanario 8 , Walters 38 and Mani et al. 35 The former two compared editors with other scientists, while the latter paper compared the publication pattern before and after one becomes an editor, but each of these studies considered only a single subdiscipline. As for any comparison between male and female editors, and between editors and their colleagues, these are completely absent from the literature. Here, to fill the aforementioned gaps in the literature, we parsed more than 173,000 editorial pages from Elsevier-a publisher behind one-fifth of global research output, garnering one-quarter of citations worldwide 43 . This enabled us to extract information pertaining to 103,000 editors, including their affiliations, their disciplines, the names of the journals they edited and the years during which they served as editors. Collectively, these editors served on 85,000 issues of 1,167 Elsevier journals spanning 15 disciplines and multiple decades; see Supplementary Note 1 for details on how scientists' disciplines were inferred, and Supplementary Table 3 for the distribution of editors across disciplines. Furthermore, following other studies in the literature 24,[44][45][46][47] , we used a state-of-the-art classifier , allowing us to identify the gender of 81,000 editors and 4,700 editors-in-chief with high confidence; see Supplementary Table 4 for the distribution of those editors across disciplines. Finally, to retrieve the publication record of any given editor, we used Microsoft Academic Graph -a dataset of 220 million publications and 240 million scientists 48,49 , which has been widely used in the Science of Science literature 44,47,[50][51][52][53][54][55] . More specifically, we matched the editors in our dataset to the scientists in MAG based on their names, affiliations and disciplines, thereby identifying the publication records of 20,000 editors and 1,600 editors-in-chief who had a unique match in MAG; see Methods for more details on the data collection, and Supplementary Table 5 for the distribution of those editors across disciplines. The resulting datasets offer a unique opportunity to address the aforementioned shortcomings in the literature, and analyse editorial patterns at an unprecedented scale. --- Results --- Editor characteristics First, we explore the characteristics of editors-to-be before the start of their editorship and compare them with an average scientist. To this end, for every editor, we randomly select a scientist whose discipline and academic birth year-the year when their first paper was published-match that of the editor. Then, we compare the pair in terms of citation count, paper . f-j, Comparing editors with scientists over time in terms of paper count , citation count , h-index , collaborator count and percentage of those whose affiliation ranks among the top 100 . k, For each year, the mean academic age of editors upon the start of their editorship. l, Editors' paper count , editors' citation count , editors' academic age and percentage of editors whose affiliation ranks among the top 100 across disciplines; the differences in the circle sizes are exaggerated to improve visibility. Data are presented as mean ± 95% CI . --- Article https://doi.org/10.1038/s41562-022-01498-1 terms of the number of citations and papers that an editor has accumulated, as well as their affiliation rank and academic age, upon the start of the editorship. We find that Biology recruits the most highly cited editors, with 2,900 citations on average, while Chemistry recruits the most productive editors, with an average of 149 papers. In contrast, the impact seems to matter the least when recruiting editors in Philosophy, Sociology and Political Science, while productivity seems to matter the least when recruiting editors in Business and Philosophy. As for academic age, we find that Business recruits the youngest editors, with 16 years of experience on average, while Physics recruits the eldest, with 24 years of experience. We calculate the average academic age of editors across disciplines, and find it to be just over 20 years. Finally, in all disciplines, the percentage of editors affiliated with a top-ranked institution ranges from 25% to 47%, with Philosophy having the greatest percentage. --- Gender composition of editors We conclude our exploratory analysis by studying gender disparity among editors. As can be seen in Fig. 2a, although women are already underrepresented among scientists , they are even more underrepresented among editors and editors-in-chief . Moreover, the gap remained stable over the past five decades; the proportion of female editors has consistently remained around half that of female scientists, although gender parity has been steadily increasing in science in general . For example, in 2017, women represented 36% of scientists, but only 18% of editors; these proportions are extremely similar to those in 1970, when women represented 11.3% of scientists and 5.7% of editors. As for female editors-in-chief, their proportion has remained consistently smaller than that of female editors since 1970. These broad trends seem to persist when excluding Biology-the discipline with the highest h-indices, citation count, collaborator count and editor count-as shown in Supplementary Fig. 10. Let us now examine the gender disparity across disciplines. Figure 2c depicts the proportion of female editors against that of female scientists across disciplines during the 1970s, 1980s, 1990s, 2000s and 2010s. Apart from Sociology, the proportion of female scientists in any given discipline has remained greater than the proportion of female editors in that discipline; see how the vast majority of shapes fall under the diagonal. Similar patterns are observed for editors-in-chief . To obtain a better understanding of this phenomenon, we analysed the length of editorial careers, that is, the number of years during which editors assume their role. The box plot in Fig. 2d compares the average editorial career length of women versus men, while the scatter plot compares these quantities across disciplines. As can be seen, the editorial career length of men 4.99 to 5.08) is greater than that of women ; this holds across all disciplines except Sociology. Supplementary Fig. 12 shows similar patterns for editors-in-chief , with the editorial career length of male editors-in-chief being greater than that of their female counterparts in all disciplines except Engineering, Geology and Materials Science. As we have shown thus far, women have been consistently underrepresented on editorial boards across disciplines over the past decades. Let us now investigate whether this phenomenon can be explained by gender differences in productivity, impact and career lengths, or whether additional hidden factors are at play. To this end, we use a randomized baseline model whereby each editor is replaced with a randomly chosen scientist who may have a different gender but is identical in terms of discipline and academic age , and similar in terms of productivity and impact . In this model, the randomly selected scientist replaces the original editor for the entire duration of his/her editorial career. Such a null model simulates a world where the editors in each discipline are recruited solely based on their experience and research output while completely disregarding their gender. We generated 50 such worlds and computed the average percentages of female editors and editors-in-chief therein. It should be noted that such analysis cannot be done using any of the datasets previously considered in the literature, as it requires the publication records of not only the editors but also all research-active scientists in any given discipline. The results of this analysis are depicted in Fig. 2e. As can be seen in the left panel, the representation of women among editors in a randomized world exhibits similar trends to those observed in the real world. This suggests that the gender gap among editors can be explained by the lack of women with sufficiently high productivity and impact, which, in turn, can be explained by attrition of women from academia 47 . In contrast, looking at the right panel of Fig. 2e, we find a clear and persistent gap between the real and counterfactual worlds in terms of the proportion of female editors-in-chief. This suggests that factors other than career length, productivity and impact may be at play, and these factors seem to persist over the past five decades. --- Editors' self-publishing behaviour Having analysed the gender disparity in editorial boards, we now shift our attention to another interesting aspect of editorship-the fact that some editors publish original research in the journal they edit. To reiterate, editorials are consistently excluded throughout this study; see Methods for details on how editorials are identified. We start off by analysing the editors' self-publication rate-the percentage of their papers published in their own journal-during the 5-year period following the start of their editorship. Based on this, as well as the fact that the publication records we extract from MAG do not go beyond 2018, we restrict this analysis to the 12,995 editors who start editing their respective journals no later than 2014. For editors who quit before completing 5 years, the self-publication rate is measured only over the years during which they serve as editors, rather than over the full 5-year period following the start of their editorship. Let us start by examining the cumulative distribution of self-publication rates. We find 24% of editors publish at least one-tenth of their papers in the journal they edit . There is also a considerable percentage of editors who publish at least one-fifth of their papers or even one-third of their papers in their own journal. Among editors-in-chief, these percentages are even higher . More specifically, 32% of editors-chief publish at least one-tenth of their papers in the journal they edit, 19% self-publish at least one-fifth of their papers and 11% self-publish one-third of their papers. For a breakdown of these distributions across disciplines, see Supplementary Figs. 13 and14. Next, we examine the correlation between the self-publication rate of the editors-in-chief and their editorial board . To improve the visualization, the data points are plotted on a log-log scale while omitting zero values; see Supplementary Fig. 15 for a linear-scale version of this plot. As can be seen, there is a significant positive correlation between the self-publication rate of the editor-in-chief and that of the editorial board, suggesting that the two are linked. To better understand these patterns, for every e,j pair we compare e with randomly selected scientists who are not editors of j but are similar to e in terms of gender, discipline, rank of first affiliation and years during which they are research-active. Additionally, we ensure that e and their matched scientists are similar in terms of the rate at which they publish in j up to year 0 . Note that this matching process is different from the two matching processes used earlier in Figs. 1 and2e; see Methods for more details. Also note that the matched scientists may themselves be editors of other journals. As such, the outcome of this analysis reflects the difference between those who edit j and those who do not, rather than the difference between editors and non-editors. The results of this analysis are depicted in the upper row of Fig. 3d. As shown in this figure, regardless of the rate at which e Article https://doi.org/10.1038/s41562-022-01498-1 publishes in j, there is a marked gap between e and their matched scientists. This observation suggests that the difference in the rate at which e and their matched scientists publish in j is associated with e becoming an editor of j, bearing in mind that both of them published in j at comparable rates before year 0 as shown in Supplementary Fig. 16 and Supplementary Table 6. A possible explanation for the observed increase in publication rate is the journal's culture, whereby editors are expected to contribute papers as part of their editorial duties. To determine whether this is the case, for every editor e whose self-publication rate is ≥ 10%, ≥ 20%, …, ≥ 50%, we compare the self-publication rate of e to that of the average editor serving at the same time on the same editorial board. This comparison considers the years after, but not before, e becomes an editor, as these are the years during which the publication rate of e in j could be influenced by the Self-publication rate ≥ 20% Self-publication rate ≥ 30% Self-publication rate ≥ 40% Self-publication rate ≥ 50% Fig. 3 | Self-publication rates. a, Cumulative distribution of editors' selfpublication rate, highlighting the proportion of those whose rate is ≥ 0%, ≥ 20%, …, ≥ 50%. b, The same as but for editors-in-chief. c, Correlation between the self-publication rates of editors-in-chief and their editorial boards; r represents the two-sided Pearson correlation coefficient, while the shaded region represents 95% CI of the regression estimate. d, Comparing editors whose self-publication rate is ≥ 10%, ≥ 20%, …, ≥ 50% to their matched scientists and to their colleagues in terms of the percentage of papers published in the editor's journal. e, Out of all men and women, the percentage of those who fall among the top 5% and 10% of editors with the highest selfpublication rates; P values are calculated using two-sided Fisher's exact tests, n male = 11,017, n female = 1,978. f, The same as , but for those who have the largest number of papers published in their own journal . g, Regression-estimated temporal trend of the self-publication rate during the 5 years before, and the 5 years after, one becomes an editor; see Supplementary information for model specifications. h, The same as , but the outcome is the number of self-published papers, measured in terms of standard deviations . Data are presented as mean ± 95% CI in through . --- Article https://doi.org/10.1038/s41562-022-01498-1 journal culture. As shown in the bottom row of Fig. 3d, regardless of e's self-publication rate, they publish in j at a greater rate than their average colleague. Finally, we check whether there exist gender differences in terms of self-publication rate, as well as the number of self-published papers. To this end, we first calculate the percentage of men, and the percentage of women, who fall among the top 1%, 2%, …, 10% of editors with the highest self-publication rates . We find that men and women are equally likely to be found among those with the highest self-publication rates . In other words, the gender composition of those with very high self-publication rates roughly reflects that of all editors. However, if we calculate the percentage of men, and the percentage of women, who fall among the top 1%, 2%, …, 10% of editors with the largest number of self-published papers , we find more men among those with the highest numbers of self-published papers, and this difference is statistically significant . In other words, while men account for 84.8% of all editors, they account for 88.2% of the top 10% editors with the highest number of self-published papers. To further investigate the gender differences in self-publication behaviour, we introduce a regression model to estimate the temporal trend of an editor's self-publication rate each year, while allowing a structural break of the trend to happen around the time that one becomes an editor. Additionally, the regression model controls for gender as well as journal fixed effects . The model indicates that the self-publication patterns of editors exhibit statistically significant discontinuity around the time when the editorship starts, as both the intercept and the slope change significantly, providing further evidence of the link between becoming an editor of a journal and increasing the rate at which one publishes in that journal. The model also indicates that, around the start of the editorship, male editors show a higher increase in their self-publication rates compared with female editors. We repeat the same regression analysis but change the outcome to be the number of self-published papers per annum . Again, the model shows that the self-publication patterns of editors exhibit significant discontinuity around the time when the editorship starts, and male editors have a higher increase in the number of self-published papers after becoming editors. To understand the limits of the above phenomenon, that is, the extent to which editors self-publish while continuing to serve on the editorial board, we identified the 15 editors who publish the highest percentage of papers in their journals during editorship. For each of them, we plotted the number of papers published per year throughout their scientific careers aggregated over 5-year periods, highlighting in different colours the proportion of the papers published in the journal they were editing; see Fig. 4a-c for the three most extreme editors, and Supplementary Fig. 18 for the remaining 12. In these figures, random perturbations are added to the counts to preserve anonymity. Focusing on the most extreme editors, out of all the papers they published throughout their career, 72%, 66% and 65% were in their own journal while they were serving as editors. These cases demonstrate that even if an editor publishes three-quarters of their entire career output in their own journal, they may continue to serve as editors for several decades. Similar trends were observed when considering the 15 most extreme editors; see Supplementary Fig. 18. It is worth mentioning that 14 out of those editors are men, suggesting that women are less likely to engage in such extreme behaviour. Also noteworthy is the fact that 6 out of the 15 extreme editors are, in fact, editors-in-chief. Having analysed extreme editors, let us now focus on the three extreme editorial boards corresponding to the journals with the highest percentage of papers authored by their editors. The results are depicted in Fig. 4d-f, which follow a similar layout compared with our previous analysis of extreme editors. Starting with the most extreme journal , one-third of the papers published therein have an active editor among the authors. As for the second and third most extreme journals , one-fifth of the papers published therein include authors who happen to be active editors. These cases demonstrate that editorial board members can author a substantial share of the papers published in the journal, and continue to do so for several decades. --- Discussion Despite efforts to increase women's representation on editorial boards 57 , the present findings reveal a persistent gender gap. Using an unprecedented dataset, our study contributes to the literature in two ways. First, we were able to examine the gender distribution among scientists and editors over the past five decades, revealing that the proportion of female editors persisted at about half that of female scientists, and that the proportion of female editors-in-chief has consistently been even smaller. Second, we were able to compare the gender gap across 15 disciplines, revealing that women have been consistently underrepresented among editors and editors-in-chief in every discipline other than Sociology. Furthermore, while gender disparity has often been measured in terms of impact 58,59 , productivity 58 and career length 47 , we showed that, at least for editors-in-chief, gender disparity goes beyond what is predicted by these numbers, indicating a systematic role for non-meritocratic factors in the selection of editors-in-chief. This resonates with the past findings that women face a 'glass ceiling' in their professional careers 60 , and suggests that women face additional obstacles in being recognized as elite scientists in their respective disciplines. Overall, this study contributes to the literature advocating a more inclusive editorial board in particular, and a more inclusive scientific community in general 29,61 . We also showed that a substantial amount of editors publish in the journal they edit, and provided the first comparison, to our knowledge, of self-publication behaviour across disciplines and genders. As such, our study contributes to the line of research exploring gender differences in academia [62][63][64][65] . Moreover, our unique dataset allowed us to understand how far editors can reach with their self-publication practice. Naturally, these findings raise the question: How much self-publication should be considered too much? Of course, there are perfectly innocuous explanations of why editors self-publish. Some may conduct research in a niche field with only a few alternative journals to publish in; others may be established scientists who self-publish their best works to boost the reputation of a young journal. Still, if there is anything that can be learned from recent scandals involving editors 39,40,66,67 , it is that the power enjoyed by editors can be exploited. For instance, consider those editors-in-chief who self-publish at high rates, despite being responsible for overseeing the review process of every submission, including their own. To an external observer, it may not be entirely clear how such articles are handled to circumvent the apparent conflict of interest. By providing an overview of the status quo of self-publishing practice, our study contributes to the discussion of whether self-publications should be governed with more transparency. Our study is not without limitations. First, our work comes with the inherent restrictions of observational studies. In particular, although we use standard techniques such as matching and randomized baseline models to further our understanding of gender inequality and self-publication patterns, it is hard to pinpoint the underlying mechanisms behind these findings; this constitutes a potential direction for future research. Second, all analyses are done using editor data collected from Elsevier. Although this is the largest publisher in academia, other publishers could also be explored, which is left to future studies. Lastly, to infer gender at scale, the only practical solution was to use algorithmic tools. Despite their advantages, such tools are not 100% accurate. Although we restricted our analysis to names that are Article https://doi.org/10.1038/s41562-022-01498-1 classified with at least 90% accuracy throughout the study, manual classification is likely to be more accurate. There is more to the story of scientific publishing than statistics. Behind the numbers, some editors stand up for a more transparent selection of papers, and actively recruit board members from underrepresented groups, while others exploit their power to benefit their careers. After all, editors are humans. Our expectation of human behaviour in imperfectly transparent institutions determines the narrative: Is it reassuring that the majority of editors hardly self-publish? Or is it striking that 11% of editors-in-chief publish at least one-third of their papers in the journal they edit? Should we be satisfied with the increasing proportion of female editors over the past decades? Or should we be concerned that, despite all efforts to promote gender equality, women are still underrepresented among editors in nearly all To preserve anonymity, ticks on the x axis and y axis are hidden and Gaussian noise is added to the bar heights. Out of all editors who publish at least 30 papers throughout their careers, subfigures , and correspond to the editor with the highest, second highest and third highest number of self-publications, respectively. For each of these editors, we show the total number of papers they publish as well as how many of those papers are published in the editor's journal; results are aggregated over 5-year periods to preserve anonymity. The horizontal line underneath the plot represent the span of the editorship. Out of all journals that have at least 30 papers, subfigures , and depict the journal with the highest, second highest and third highest proportion of papers whose authors include an editor of that journal, respectively. --- Article https://doi.org/10.1038/s41562-022-01498-1 disciplines? Either way, we hope our study, and the future work it may inspire, will contribute to a fairer, more transparent and more inclusive culture of scientific editorship. --- Methods --- Data Data collection. Elsevier published 4,289 different journals in 2019, all of which are listed on ScienceDirect-a website operated by the publisher 68 . Each journal curates some or all of its past issues, and all of the articles that appeared in every curated issue. In addition to research articles, many journals list their editors on the Editorial Board page, which can be found in the first volume of each issue. These pages, which constitute the primary source of our editor-related data, were retrieved using the Elsevier Article Retrieval API 69 . In total, we collected 173,434 editorial board pages from 1,893 different journals. From these pages, we were able to extract the following information about each journal: title, issue, volume, discipline, publication date, editors' names, editors' affiliations and whether or not any given editor is an editor-in-chief. To retrieve the publication records of these editors, we paired them with scientists from the MAG dataset. In particular, an editor in Elsevier and a scientist in MAG are considered to be the same person if, and only if, they uniquely share the same name and affiliation. For details on how the name disambiguation problem is addressed in this study, see Supplementary Note 2. For any e,j pair, the first year of editorship is assumed to be the publication year of the first issue of j in which e is mentioned as an editor. Moreover, the editorial career of e is assumed to span the period between the first and last years of editorship , implying that any gap years are included in our analysis. Similarly, the academic career of any scientist s is assumed to span the period between the publication years of their first and last papers. As a result, the academic age of s in any given year y is y -year s first + 1, where year s first is the publication year of the first paper of s. Editorials were then excluded from the publication record of each editor, to ensure that it consisted of scientific papers. To this end, we queried ScienceDirect to identify the type of each publication in Elsevier, and excluded over 13,000 publications falling under the following types: Book review, Conference info, Editorial, Encyclopedia, Erratum, News, Practice guideline and Product review. This left us with about 168,000 publications authored by the 20,000 editors identified in MAG. Out of those publications, we randomly sampled 200 and manually verified that only two were, in fact, editorial pieces. Additionally, we manually examined all publications authored by the three extreme editors considered in Fig. 4, and again found that only two were editorial pieces. This analysis suggests that our approach of identifying and excluding editorial pieces, while not perfect, is highly accurate. Gender identification. Several gender classifiers have been proposed to date 58,70,71 . Following other studies in the literature 24,[44][45][46][47] , we use Genderize.io, which has been shown to outperform other alternatives 70 . This classifier integrates publicly available census statistics to build a name database, mapping names to binary gender labels. In our gender-related analysis, we only considered scientists whose first names were classified with a confidence of ≥ 90%. Dataset evaluation. In our gender-based analysis, we considered a dataset consisting of the 81,000 editors whose gender has been identified by Genderize.io with confidence of ≥ 90%; let us denote this dataset by E gender . On the other hand, when analysing the publication patterns of editors, we considered a dataset consisting of the 20,000 editors who had a unique matching entry in MAG, denoted by E MAG . These two datasets are likely to exhibit biases as they were not randomly sampled from all 103,000 Elsevier editors, denoted by E all . In this section, we aim to understand how these biases could affect our main findings. We start off by comparing E gender to E all in terms of the relative size of each discipline. We found that the two are highly correlated ; see Supplementary Fig. 19a. High correlation could also be seen when comparing E MAG with E all ; see Supplementary Fig. 19b. Nevertheless, some disciplines are underrepresented compared with E all , while others are overrepresented. As a result, the observed proportion of women in E gender may differ from that in E all , and the observed proportion of editors in E MAG whose self-publications rates are ≥ 10%, …, ≥ 50% may also differ from that in E all . As shown in Supplementary Fig. 19a, Medicine is overrepresented in E gender , which could affect our gender-based findings, especially as Medicine amounts to more than a fifth of all editors in E gender . For instance, if this discipline happens to have fewer female editors than average, then our estimation of the gender gap would be an overestimation of the overall gender gap . To estimate the gender gap in E all , we multiplied the proportion of women in each discipline in E gender by the size of that discipline in E all . Similarly, to estimate the percentage of editors whose self-publications rates are ≥ 10%, …, ≥ 50% in E all , we multiplied their proportion in each discipline in E MAG by the size of that discipline in E all . As a result, the proportion of female editors becomes 12.95% , and the percentage of editors whose self-publication rate is ≥ 10%, ≥ 20%, ≥ 30%, ≥ 40% and ≥ 50% becomes 27.21%, 13.79%, 7.71%, 4.88% and 3.66%, respectively . This suggests that the situation may be grimmer than originally estimated, as the gender gap seems to be larger, and self-publication seems to be more widespread, once we adjust for differences in discipline size. Next, we examine how representative E MAG is of E all in terms of the editors' publication patterns. As there are no available datasets that provide the publication profiles of all 103,000 editors in E all , a practical alternative is to compare E MAG with a random sample of E all , after manually identifying the publication profile of each sampled editor. Unfortunately, this approach also comes with its own limitations, as many editors do not have an online presence, making it extremely challenging, if not impossible, to manually identify their publication profile. With these limitations in mind, we sampled 500 editors from E all and were able to manually identify the MAG entry of 264 of them using information available online; the set of those 264 editors is denoted by E manual . Then, we compared E MAG with E manual in terms of the confounders examined earlier in Fig. 1, namely: paper count, citation count, collaborator count, h-index, academic age and percentage of those affiliated with a top 100 institution. We found significant differences between E MAG and E manual in terms of paper count, collaborator count, h-index and percentage of editors whose affiliation is among the top 100; see Supplementary Fig. 20. These differences may lead to a biased estimation of the percentage of each type of editor. As a sensitivity analysis, we re-sampled the editors in E MAG so that the distributions of all confounders are similar to E manual . After re-sampling, we found the percentage of editors whose self-publication rate is ≥ 10%, ≥ 20%, ≥ 30%, ≥ 40% and ≥ 50% becomes 24.23%, 12.72%, 7.61%, 5.02% and 4.04%, respectively , and there is no significant difference between E MAG and E manual in terms of those percentages using two-sided Fisher's exact tests. This analysis suggests that the differences in the above confounders do not bias the estimation of the percentage of editors with high self-publication rates. Note that the aforementioned re-sampling is only done as a part of this sensitivity analysis, and does not affect any other result in our study. --- Matching editors to scientists In three parts of our study, we used matching techniques to compare editors against scientists with comparable attributes. This section provides detailed descriptions of each matching process. First, in our descriptive analysis , we aim to compare editors with average scientists who work in the same discipline and have the same academic age. Based on this, for each e,j pair, we compare e Article https://doi.org/10.1038/s41562-022-01498-1 to scientists whose discipline and academic birth year-the year when their first paper was published-are the same as that of e. Second, as part of our analysis of gender disparity, we apply a matching technique to test the hypothesis that the underrepresentation of female editors can be explained by their lower publication and citation rates. To this end, for any e,j pair we randomly sample 50 scientists whose discipline and academic birth year are the same as e, and whose productivity and impact by the end of year 0 are comparable with e . Third, in our analysis of self-publication patterns, we apply a matching technique to analyse the editors whose self-publication rate is higher than a certain percentage. Here, the hypothesis is that the observed self-publication rate of an editor e in their own journal j can be explained by characteristics of e that are unrelated to e becoming an editor. To this end, given an e,j pair, we match e to a scientist s who is not an editor of j based on a number of confounders, including the rate at which they publish in j. Ideally, the rate of e and s should be similar up to year 0 0 , it suggests that the divergence is related to e becoming an editor of j). However, to increase the likelihood of finding a match for e, we do not require the rate of s to match that of e in year 0 , but rather in a year y such that | year 0 -y| ≤ 3. More specifically, we say that e matches s in year y if all of the following conditions are met: The academic age of e in year 0 does not differ from that of s in y by more than 10%. The percentage of papers that e published in j in year 0 does not differ from that of s in y by more than 10%. The percentage of papers that e published in j up to year 0 does not differ from that of s in y by more than 10%. --- nature portfolio | reporting summary March 2021 --- Data exclusions In order to perform gender-related analysis, we identify the gender 81,000 editors with at least 90% accuracy. The remaining ones were excluded from our gender-based analysis. This exclusion criteria was pre-determined, following past studies. In order to perform bibliometrics analysis, we were able to identify the publication records of 20,000 editors. The remaining ones were excluded from our bibliometrics analysis. This exclusion criteria was pre-determined to avoid the arduous task of manually identifying editors from over 200 million scientists recorded in MAG. For more discussion regarding the mentioned data exclusion, please see the "Dataset Evaluation" subsection in the Methods section of our main manuscript. --- Non-participation There were no participants involved. --- Randomization There were no participants involved. --- Reporting for specific materials, systems and methods We require information from authors about some types of materials, experimental systems and methods used in many studies. Here, indicate whether each material, system or method listed is relevant to your study. If you are not sure if a list item applies to your research, read the appropriate section before selecting a response. --- Data availability Our editors' dataset was collected from Elsevier's ScienceDirect database. A formal agreement between us and Elsevier mandates that data copied from the subscribed products cannot be provided to third parties in any substantial or systematic manner. However, for transparency reasons, we provide a sample set of 10 editors, which can be used to test the code for data collection and analysis, along with anonymized data for reproducing figures, all the while ensuring that our agreement with Elsevier is not breached. As for our publications' dataset, that is, the Microsoft Academic Graph, a copy of it is available at https:// zenodo.org/record/2628216#.Y4i9mnbP2Ul ; a small subset of MAG that is sufficient to test our code is also provided. To retrieve the aforementioned datasets, visit the following link: https://github.com/ Michael98Liu/fair-and-inclusive-scientific-publishing/tree/main/data . If you would like to obtain permission to collect and analyse data provided by Elsevier, please contact their customer consultant at [email protected]. --- Code availability The Python code used to collect and clean the editors' dataset, as well as the code used in the analysis and visualizations, are all freely available to download from https://github.com/Michael98Liu/ fair-and-inclusive-scientific-publishing. --- Reporting summary Further information on research design is available in the Nature Portfolio Reporting Summary linked to this article. --- --- Competing interests The authors declare no competing interests. --- Reporting Summary Nature Portfolio wishes to improve the reproducibility of the work that we publish. This form provides structure for consistency and transparency in reporting. For further information on Nature Portfolio policies, see our Editorial Policies and the Editorial Policy Checklist. --- Statistics For all statistical analyses, confirm that the following items are present in the figure legend, table legend, main text, or Methods section. --- n/a Confirmed The exact sample size for each experimental group/condition, given as a discrete number and unit of measurement A statement on whether measurements were taken from distinct samples or whether the same sample was measured repeatedly The statistical test used AND whether they are one-or two-sided Only common tests should be described solely by name; describe more complex techniques in the Methods section. --- A description of all covariates tested A description of any assumptions or corrections, such as tests of normality and adjustment for multiple comparisons A full description of the statistical parameters including central tendency or other basic estimates AND variation or associated estimates of uncertainty For null hypothesis testing, the test statistic with confidence intervals, effect sizes, degrees of freedom and P value noted Give P values as exact values whenever suitable. For Bayesian analysis, information on the choice of priors and Markov chain Monte Carlo settings For hierarchical and complex designs, identification of the appropriate level for tests and full reporting of outcomes Estimates of effect sizes , indicating how they were calculated Our web collection on statistics for biologists contains articles on many of the points above. --- Software and code --- Policy information about availability of computer code Data collection Data about editors was collected using EISevier's Article Retrieval API: https://dev.elsevier.com/documentation/ArticleRetrievalAPl.wadl Data about the publication records of individual scientists was retrieved from the Microsoft Academic Graph website. The gender of the authors in the dataset, was collected from the API of Genderize.io. The code used to collect and clean data can be found in our Github repository . --- Data analysis Data analysis was done using computer programs written in the Python programming language . You can find the code in our Github repository . For manuscripts utilizing custom algorithms or software that are central to the research but not yet described in published literature, software must be made available to editors and reviewers. We strongly encourage code deposition in a community repository . See the Nature Portfolio guidelines for submitting code & software for further information. --- nature portfolio | reporting summary March 2021 --- Data Policy information about availability of data All manuscripts must include a data availability statement. This statement should provide the following information, where applicable: -Accession codes, unique identifiers, or web links for publicly available datasets -A description of any restrictions on data availability -For clinical datasets or third party data, please ensure that the statement adheres to our policy Our editors' dataset was collected from Elsevier's ScienceDirect database. A formal agreement between us and Elservier mandates that data copied from the subscribed products cannot be provided to third parties in any substantial or systematic manner. However, for transparency reasons, we provide a sample set of 10 editors, which can be used to test the code for data collection and analysis, along with anonymized data for reproducing figures, all the while ensuring that our agreement with Elsevier is not breached. As for our publications' dataset, i.e., the Microsoft Academic Graph, a copy of it is available at https://zenodo.org/ record/2628216#.Yx9BbexBza4; a small subset of MAG that is sufficient to test our code is also provided. To retrieve the aforementioned datasets, visit https:// github.com/Michael98Liu/fair-and-inclusive-scientific-publishing/tree/main/data. --- Human research participants Policy information about studies involving human research participants and Sex and Gender in Research. --- Reporting on sex and gender There were no participants involved. --- Population characteristics See above. --- Recruitment There were no participants involved. --- Ethics oversight There were no participants involved. Note that full information on the approval of the study protocol must also be provided in the manuscript. --- Field-specific reporting Please select the one below that is the best fit for your research. If you are not sure, read the appropriate sections before making your selection. --- Life sciences Behavioural & social sciences Ecological, evolutionary & environmental sciences For a reference copy of the document with all sections, see nature.com/documents/nr-reporting-summary-flat.pdf Behavioural & social sciences study design All studies must disclose on these points even when the disclosure is negative. --- Study description We use matching techniques to study the relationship between editors assuming their roles and their publication patterns. We used randomized baseline models to understand the relationship between the population of female scientists and female editors. The data is quantitative. --- Research sample We focus on all Elsevier journals, and study all editors whose name can be automatically retrieved from Elsevier database using the aforementioned computer program and API. Data is collected using computer program, and therefore demographics information is not available. The sample of editors that we study is not meant to be a representative sample of all editors in the world. We choose to study Elsevier because it is one of the largest publishers, by generating one fifth of global research output, and garnering one quarter of citations worldwide. This study also uses an existing dataset called the Microsoft Academic Graph . --- Sampling strategy We use convenience sampling. Our sample consists of all those whose name can be automatically extracted from Elsevier database. No sample-size calculation was performed; rather, we study all 103,000 editors whose name is identifiable. These data is sufficient since they cover 15 different scientific disciplines, and span over four decades. --- Data collection The publication dataset was downloaded from Microsoft Academic Graph's website. The editors dataset was collected using Elsevier's Article Retrieval API. There were no participants involved; researchers were aware of the research hypothesis during data collection. --- Timing The data was collected in January 2020.

Peer review information Nature Human Behaviour thanks the anonymous reviewers for their contribution to the peer review of this work. Reprints and permissions information is available at www.nature.com/reprints.

INTRODUCTION Associations between social situation and health or access to care are well established. [1][2][3][4][5][6][7] Pregnancy is no exception, and associations have been described between social situation and medical complications during pregnancy or the neonatal period, especially preterm birth, growth retardation or infant mortality. [8][9][10][11][12][13][14] In such studies, social situation is measured in different ways. It can be assessed with socioeconomic indicators such as income, educational level or occupational status, 2 3 8 10 11 or sometimes with more complex scores aggregating several social characteristics. 1 9 15-19 Thus, Townsend 15 measured privation of a population with a territorial score, regrouping the following characteristics: rate of unemployment, overcrowded housing, not having a car, and not having personal accommodation. Borrell et al 1 evaluated social deprivation using a socioeconomic index based on the features of an area: proportion of unemployment, manual workers, foreigners, and low education. Sass et al 19 evaluated individual deprivation with 11 questions, such as meeting a social worker, not having social insurance, having financial difficulties, or amount of time spent on spare-time activities. This multiplicity of indicators attests to the complexity of social vulnerability. In 1987, Wresinski 20 defined it as the lack of one or more securities enabling people to assume their elementary responsibilities and enjoy their fundamental rights. It can be more or less expansive and have more or less severe consequences. Deprivation can be measured at the geographical level, rather than individually. 1 11 13 15 16 In some studies, the socioeconomic situation of a residential area is used as proxy for individual deprivation. 11 21 However, in health and especially for pregnant women, although residential area affects --- Strengths and limitations of this study ▪ The main strength is the large and representative sample of births with a lot of social data allowing a deep analysis of social deprivation. ▪ The main limitation is the specificity of this index to France because it includes benefitfrom some social measures. Generalisation of this index will require adaptation of some of its components to the legislation of each country. the individual, the social situation of the person has a major impact. 2 22-25 As mentioned above, in order to measure more precisely social vulnerability with its multidimensional aspects, some authors have developed social indexes. However, the existing scores are generally not suitable for pregnancy. Moreover, they are complex and difficult to use in situations other than data collection for surveys. The aim of this study was to identify markers of deprivation for pregnant women that differ from the usual socioeconomic variables and show how they relate to medical care and pregnancy outcome. Aggregating these markers into a score will enable us to assess multidimensional social vulnerability and measure a deprivation gradient that is suitable for the period of pregnancy and easy to use in any situation. --- METHODS --- Data A National Perinatal Survey of a nationally representative sample of births was performed in March 2010 . Data collection covered all births in France during 1 week-that is, all liveborn or stillborn children, in public and private maternity units, as well as children born outside these facilities and then transferred to one, at a gestational age of least 22 weeks or with a weight at least 500 g at birth. 26 Data were obtained from two sources: an interview with mothers in the postpartum ward about their social and demographic characteristics and their behaviours during pregnancy and prenatal care; medical records on complications during pregnancy or delivery and the child's health status at birth. The National Council on Statistical Information and the French Commission on Information Technology and Liberties approved this survey. --- Variables Social and demographic characteristics were collected by interviewing the women. Variables studied were age, nationality, educational level , occupation of the woman and of her partner , household income and household allowances during pregnancy, social insurance at the beginning of the pregnancy, housing situation, and the mother forgoing healthcare because of financial reasons. From these variables, six indicators of social deprivation during pregnancy were developed: the household receiving unemployment allowance; the household receiving the minimum resource allowance ); the woman having universal health insurance ) or not insured; the woman forgoing healthcare for financial reasons; the woman not living in personal housing; the woman not living with a partner. Two variables used in the analysis refer to social benefits introduced in France to help deprived people: the RSA allowance and the CMU insurance. Since 2009, RSA ensures a minimum income for people who have few resources. This allowance supplements the household's initial income to reach a guaranteed threshold. Since 2000, CMU has improved access to care with a generalisation of social security for people who do not benefit from it. So, if people are permanently residing in France, their medical costs are covered by social security under the same conditions as those who are insured. Some variables describing behaviours during pregnancy, antenatal care and outcomes of the pregnancy were considered: unwanted pregnancy; late onset of prenatal care; smoking tobacco during the third trimester; preterm birth; small for gestational age . Pregnancy was considered 'unwanted' when the mother declared that she would have preferred to be pregnant later or not be pregnant. The onset of prenatal care was considered 'late' when the pregnancy was declared after the first trimester. Indeed, declaration of the pregnancy is the first mandatory step in order to be well covered by social security. Preterm birth was defined as birth before 37 weeks of amenorrhoea, and SGA as birthweight under the 10th centile for gestational age and sex according to AUDIPOG curves. 27 --- Statistical analysis Correlation analysis was first performed with the six deprivation indicators and then multiple correspondence analysis . MCA is a 'data reduction' procedure. It analyses the pattern of relationships between categorical variables and summarises the information contained in the initial variables into factors that are easier to interpret. These factors are weighted linear combinations of the initial variables and are represented by axes that assemble variables present in similar individuals. 18 28 The variables emerging from the first axis of MCA were combined into an index to measure social deprivation. The association between this new score and various socioeconomic variables was then explored to describe the characteristics of women in every class of the score. Finally, associations between the score and variables describing behaviours, antenatal care and outcome of the pregnancy were analysed by logistic regression, with adjustment for age, nationality and educational level of the mother, and then with income. Statistical analysis was performed using SAS V.9.3. --- RESULTS The sample included 14 681 women living in metropolitan France. The analysis used data for 14 326 women with a liveborn singleton; 4.1% of the records for these women were incomplete or empty, which was due to refusal, language barrier, or early discharge of the mother. Overall, 14.0% of women benefitted from CMU or did not have any social insurance, 14.4% of women or their partner received unemployment insurance, and 10.3% received RSA; 7.3% of women reported that they did not live with a partner, and 7.2% did not live in personal housing; forgoing healthcare for financial reasons concerned 4.4% of the sample . Women who did not respond to any of these four questions were excluded ; 1.8% of women had one, two or three missing answers. Missing data were coded as '0'. Missing data was more common for women in poor social situations. Correlations between these different indicators of deprivation were highly significant , except for two variables: unemployment allowance and forgoing healthcare. Despite strong associations, correlation coefficients between variables were low . All variables were retained for the rest of the analysis. MCA was conducted with the six indicators, as shown in table 1. The factorial analysis generated two principal axes with significant inertia : the first one with inertia of 0.35, and the second one with inertia of 0.17. The first axis contrasted women with one or more of the following characteristics with women without these characteristics: benefitting from the CMU or without insurance, receiving RSA, not living in personal housing, and not living with a partner. It can be identified as a deprivation axis: the position of the woman on the axis reflects her degree of deprivation. The second axis was less easy to interpret. It put together the women receiving unemployment allowance and those forgoing care for financial reasons. These results were consistent with the correlation analysis. The first axis, with four characteristics, was retained to create a score of deprivation, a gradual marker of social vulnerability. Contributory variables were combined into a pondered sum, with the weights provided by the MCA. The score was compared with a simple sum of the four characteristics: when an indicator was present, one point was added to the sum. The values of the simple sum ranged from 0 to 4. The comparison, not presented here, showed an exact match between the two indices. Therefore, the non-pondered sum was retained. The index value was 0 for 78.2% of the sample, 1 for 10.8%, 2 for 6.2%, and ≥3 for 4.7%. The score was strongly related to social and demographic variables . Compared with women with a zero score, women with a high score were more often young, under 25 years old, and foreign. They often had a low educational level and low household income and lived in jobless households. Therefore, these results confirmed that the index adequately identifies women in difficult social situations. Associations between the score and some outcomes were tested . The higher the score, the higher the risk of unwanted pregnancy, late onset of prenatal care, and smoking during the third trimester. Even after adjustment for age, nationality and educational level, these associations remained highly significant. Checking collinearity showed that nationality and level of education are related, but they do not describe the same reality; each variable adds useful information, and, thanks to the large sample size, the quality of the models is good. Finally, the deprivation index was associated with pregnancy outcomes: the score was associated with SGA, and, with score ≥1, the risk of preterm birth was increased. After adjustment, the relation between these variables remained significant. The risk of preterm birth mainly increased for women with one deprivation indicator. On adjustment for household income, the deprivation index remained strongly associated with prenatal care and behaviours during pregnancy. The association persisted for preterm birth but not for SGA . In comparison with other social variables, such as educational level, occupational status and household income, this index shows, as well or better, the differences in results . For instance, concerning the level of education, 20% of the women without high school education did not want to be pregnant , 13% announced their pregnancy after the first trimester , 30% smoked during pregnancy , 7% had a preterm birth , and 10.5% had a baby that was SGA . --- DISCUSSION Our statistical analysis brings out four indicators of social deprivation for pregnant women in France: household receiving RSA allowance; woman benefitting from the CMU or not having medical insurance; woman not having personal housing; woman not living with a partner during pregnancy. These variables were combined into an index to measure deprivation, highlighting a social gradient. This approach has been used by others; some studies have developed a geographical index, 1 12 13 15 16 sometimes used to address the lack of individual information. 11 21 Other studies, less numerous, have resulted in indicators of individual poverty; they generally measure social disadvantage. 9 17-19 29 The most common method of creating an index is principal component analysis . 12 22 We prefer MCA. Indeed, MCA is suitable for qualitative variables, unlike PCA, which is designed for continuous variables with normal distribution. In addition, with PCA, variables with a greater number of subjects play a greater role in the analysis. MCA, through the χ 2 distance, helps balance the weight of each modality. It is important because indicators of deprivation are poorly represented in the population. 18 19 28 29 This index is strongly related to the usual social characteristics: the greater the value of the index, the more difficult the social situation. In our study, women were often young , foreign, poorly educated, with low income and in a jobless household. Some authors have also compared their poverty indexes with the usual social variables; 9 19 their results describe strong links, which underscores the usefulness of summarising information as much as possible in a single indicator. Consistent with other studies, our results show that the social situation as described by the index is related to the desire for pregnancy, 9 10 prenatal care, 2 30 smoking during pregnancy, 10 and SGA infants. 15 26 The link with preterm birth is less clear despite an excess of risk as soon as the index is higher than 0, even after adjustment for the usual social variables. 13 15 So, the association between the index and the pregnancy variables is not totally explained by the usual social indicators. The deprivation index probably contains a dimension not measured by the other social variables. This idea is supported by the index showing bigger differences between women than other variables, especially concerning psychological status, behaviours, and access to care. These domains are very important during the pregnancy period. One limitation of this index is its specificity to France: two of the variables selected correspond to receiving social benefits, the RSA and CMU. More than 2 million households in France benefitted from the RSA in 2014, which is an increase of 6% since 2013, 31 and 2.3 million people benefitted from the CMU system at the end of 2013. 32 These social benefits help the poorest families. They act as both protection and deprivation marker. Some women were not included in the survey because of their refusal or their inability to be interviewed-for instance, women who did not speak French. Likewise, mothers of stillborn babies were excluded. It is likely that these women were more deprived than in our sample. Moreover, non-recourse to social benefits-RSA or CMU-is still common, affecting 35-68% of people eligible for RSA in 2011. 33 Using these variables as a component of the index means that this population is not taken into account, and deprivation in the sample is underestimated. However, in the specific context of pregnancy, women access social benefits to which they are entitled more often than does the general population. Finally, missing data, not shown here, represent about 5% of the sample for the variables of interest. They are more common among women in poor social situations. This finding may lead to bias with a slight underestimation of deprivation. Nevertheless, the link between the deprivation index and health variables, which is probably reduced by the underestimation of deprivation, is still significant. The main strength of this study is the large size of the national sample, which allowed good representation of the poorest women, and the good quality of the sample, with its representativeness at the national level. In this study, the use of a deprivation index was preferred for describing the social situation of the new mothers. The complexity of the concept of deprivation means that several situations and factors need to be taken into account in the analysis. Thus, from simple dichotomous variables, the index addresses different dimensions, such as financial resources, cohabitation, housing, and access to medical care. This index is easily reproducible, and the variables that compose it can be easily used with low risk of incorrect answers. Its use helps to address the lack of objective definitions of deprivation in obstetrics; it may be useful for practitioners for different stages of pregnancy to identify the poorest women and direct them to social workers and the services to which they are entitled. --- Competing interests None declared. --- Ethics approval The National Council on Statistical Information and the French Commission on Information Technology and Liberties approved this survey. Provenance and peer review Not commissioned; externally peer reviewed. --- Data sharing statement No additional data are available. Open Access This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial license, which permits others to distribute, remix, adapt, build upon this work noncommercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http:// creativecommons.org/licenses/by-nc/4.0/

Objectives: To identify precariousness markers in pregnant women that differ from the usual socioeconomic variables. Methods: Data were obtained from the National Perinatal Survey, a representative sample of women giving birth in France in 2010. From six indicators of social vulnerability, four were selected by multiple correspondence analysis. The first axis of this analysis was used, characterised by the following contributory variables: receiving RSA (Revenu de Solidarité Active) allowance; benefitting from the CMU (Couverture Maladie Universelle) system (French social security) or not being insured; not living in own accommodation; and not living with a partner. These four variables were summed to create a deprivation index. Results: This index was strongly associated with social maternal characteristics and correctly identified women who were socially vulnerable. Furthermore, it was highly related to the psychosocial context, access to care, behaviours during pregnancy, and pregnancy outcomes. These associations remained significant after adjustment for social variables: compared with no deprivation (no factors), a high level of deprivation (≥3 factors) was associated with late prenatal care (OR 5.8, 95% CI 4.6 to 7.2) and small for gestational age (OR 1.5, 95% CI 1.1 to 1.9). Conclusions: This index of social deprivation was associated with health issues and behaviours during pregnancy, even after adjustment for social variables, revealing a dimension not measured by the usual variables. Moreover, it is simple to use and easily reproducible.

IntroduCtIon On average, countries that are more equal have better health and well-being. 1 2 Comparisons of population data have shown that high-income countries with less income inequality have longer life expectancy, lower teenage pregnancy rates, lower infant mortality and better child well-being. [3][4][5][6][7][8] Within countries, the social gradient in health is well-established: each incremental improvement in socioeconomic circumstances brings an associated health gain. 9 It remains unclear, however, how the health benefit of living in a more equal country is distributed across society-in other words, whether or not both rich and poor do better. One previous ecological study using aggregated mortality data for rich and poor counties within US states found that mortality rates for some causes of death were lower for everyone in more equal US states, but for causes of death with no social gradient, there was no inequality effect. 10 Several studies have used individual data to compare social gradients in health in different countries. [11][12][13][14][15][16][17] When they are interpreted in relation to income inequality, they provide some indication that health is better among people at all points in the social hierarchy in more equal countries. For example, a comparative study showed that infant mortality What is known about the subject ► Countries with lower income inequality have better average health and well-being. ► There is a social gradient in child health within countries. ► There is some limited and inconsistent evidence that health is worse at all points of the social gradient in more unequal countries. --- What this study adds ► There is considerable variation in the social gap in child height between countries, suggesting that inequalities are not inevitable. ► Children are shorter at all points of the social gradient in more unequal societies, with the greatest detriment among children from the most disadvantaged backgrounds. Open access rates were higher overall and the social gradient was steeper in England and Wales than in Sweden. Infant mortality was therefore higher in all social classes in England and Wales than in Sweden, with the greatest difference among lower social class groups. 11 However, there are inconsistencies between studies. There is also ongoing discussion on the relationship between income inequality and health. Several recent reviews have concluded that health and well-being are better in more equal countries. 2 18 There are some differences by study design and outcome, with findings from longitudinal studies less consistent than cross-sectional studies, and some mixed findings from studies on child health. 19 20 The causal mechanisms of the relationship are not fully understood. 21 Investigating how the relationship between income inequality and health varies in relation to socioeconomic position can help to clarify the nature of this relationship. Understanding whether people in all socioeconomic circumstances do better in more equal countries might offer important potential policy levers to address inequality. When considering child health, and health-related indicators of lifelong health and well-being that can be measured in children, the policy implications are significant. If children's trajectories of health and well-being are shaped by both family socioeconomic circumstances and societal levels of inequality, then promoting more equitable health and life chances is a matter of social justice. Child height is a well-recognised marker of children's social and environmental conditions and general population health. Economic, nutritional and health constraints early in life, as well as psychological and social stressors such as family conflict, reduce children's likelihood of achieving their genetic height potential. 22 Height not only reflects past and current socioeconomic conditions, but is also a good indicator of future well-being and success, including better health and workplace success and higher average income. [23][24][25][26] Within countries, numerous studies have described social gradients in growth and height from birth, through childhood and into adulthood. 27 28 However, if children from affluent families are shorter in more unequal countries than equally well-off families in more equal countries, then the need for policies aimed at inequality reduction might be brought into focus. This study aimed to answer the question: how do social gradients in child height vary in relation to income inequality in high-income countries? We used child height as a marker of current and future health and well-being to investigate whether children growing up in all socioeconomic circumstances do better in more equal countries. --- Methods study design and participants We conducted a coordinated analysis of five cohort studies from countries with different levels of income inequality, using identical statistical methods and comparable variables. 29 We compared social gradients in height at age 4-6 years, by household socioeconomic position. We included three national cohorts-the US Early Child Longitudinal Study K cohort , the UK Millennium Cohort Study and the Longitudinal Study of Australian Children K cohort ; and two regional or city cohorts-the Generation R Study from Rotterdam in the Netherlands, and All Babies in Southeast Sweden from Southeast Sweden. At the time of data collection, the USA had the highest income inequality , followed by the UK , Australia , the Netherlands , and Sweden . The cohorts recruited pregnant women or infants, except the US and Australian cohorts, which recruited children at kindergarten entry. As analysis used secondary Open access data only, no additional patient and participant involvement was conducted. Processes There were differences in recruitment and sample between cohorts; therefore, we defined inclusion and exclusion criteria to maximise comparability of samples. Children were excluded if they were born outside the sample country/region, or if they were multiple births. Children were also excluded if they were from minority ethnic groups in the country, consistent with previous cross-national studies, 13 and because average height often varies by ethnicity. The final samples were singleton children aged 4-6 from the majority ethnic group who were born in the country/region in which the cohort took place. Height was selected as an objective and comparable indicator of child physical health across cohorts. Parent education level and household income were selected as indicators of socioeconomic position due to their wide use in epidemiological research, 30 availability and comparability. To harmonise parent education, we defined four levels using the highest qualification of either parent. In the USA, UK and Australian cohorts these levels were: 1-no secondary school; 2-secondary school; 3-postsecondary/technical; 4-university degree or higher. In the Netherlands and Sweden parents were highly educated, so using the same categories would not capture differences in education status within these samples. We defined education categories for these cohorts which, though technically different, were chosen to have a similar meaning in terms of social status and employment opportunities as the study countries. In the Dutch and Swedish cohorts the levels were: 1-secondary school; 2-lower technical/vocational; 3-higher technical/ theoretical; 4-university degree or higher . To harmonise household income, we calculated equivalised household income in purchasing power parity dollars at 2005 prices. We first converted household income bands to continuous values using interval regression . 31 In the US cohort we truncated the highest household incomes to improve comparability . We accounted for differences in price and currency using the Organisation for Economic Co-operation and Development consumer price index figures to calculate incomes at 2005 prices, then conversion to PPP$ using the OECD PPP$ exchange rates for 2005. Finally, we took account of differences in household size by equivalising income using the square root of the number of people in the household. --- statistical analysis We analysed each data set separately, then compared findings. As rates of missing data were generally low , we conducted complete case analysis. All analyses were conducted using STATA V.11. Descriptive statistics were calculated for socioeconomic position, health outcomes and other socio-demographic variables. We conducted preliminary unadjusted analysis of child height by parent education level and by quintiles of household income for comparability between cohorts. We then used linear regression to take differences in age and sex into account. We regressed child height on parent education level/household income, child sex and age. We investigated the presence of different relationships by child sex using interactions between socioeconomic exposure variables and sex, and non-linear relationships with income by including a squared income term when significant. Separate models were run for each cohort and for parent education and household income . Finally, we predicted height from each of the models for children in the same circumstances in each cohort, using the margins command in STATA. For parent education, height was predicted for girls and boys separately, at exactly 5 years of age, with each of the four levels of parent education. For household income, height was predicted for girls and boys, aged exactly 5 years, at the 5th, 25th, 50th, 75th and 95th percentiles of equivalised household income. These were then presented graphically to compare the slope and level of gradients between countries. We took account of sampling and attrition in the analysis and calculation of standard errors wherever possible. In the USA, UK and Australian cohorts, this was achieved using the svy commands in STATA. In the Dutch and Swedish cohorts, analyses were unweighted as weighting variables were not available. We present model coefficients with 95% confidence intervals; for inclusion of second-order terms in the models , we used a cut-off at p<0.1. --- results The total analytic sample was 37 063 children from five cohort studies . The mean age ranged from 57.0 months in the Australian sample to 72.6 months in the Dutch sample and the male/female proportion was similar across cohorts. Mean height varied considerably, in accordance with the age distribution across cohorts, and was highest in the Dutch cohort. Boys were significantly taller in all cohorts. Parent education levels were highest in the Dutch and Swedish cohorts and considerably lower in the UK cohort; household income was considerably higher in the US cohort than in other cohorts. Unadjusted social gradients in child height are reported in the supplementary file. Parent education was a significant predictor of child height in adjusted regression analysis in all cohorts . Gradients in child height by parent education were steepest in the cohorts from the most unequal countries , with marked, but less steep gradients in the cohorts from Australia and the more equal countries . In the Swedish cohort, the gradient was almost flat except for the lowest education category . There was no significant interaction between sex and parent education. Figure 1 shows predicted gradients in child height from each model for girls and boys aged exactly 5 years, by parent education level. Equivalised household income was also a significant predictor of child height in all cohorts . Gradients were steepest in the cohorts from the three most unequal countries , and less steep in the cohorts from the most equal countries . There was no significant interaction between sex and household income. girls and boys aged exactly 5 years, by household income level. Children were taller in the cohorts from the most equal countries at every parent education or income level, with the greatest difference between cohorts among children with the least educated parents . --- dIsCussIon We compared social gradients in child height to explore whether children in all socioeconomic circumstances do better in more equal countries. After adjusting for differences in age and sex, children were shorter on average and the social gradient was steepest in the cohorts from the most unequal countries. A 'fanning out' pattern was evident, with children in more equal countries taller at all levels of parent education, but with the greatest between-country differences among children with less educated parents. Analysis of social gradients in relation to household income indicated broadly similar patterns. Findings from comparison of harmonised cohort studies may reflect methodological differences between the studies, errors in the comparative method or actual population differences. 32 We needed to analyse each cohort separately, as data access requirements did not enable pooling of the data sets. The coordinated analysis enabled a high degree of harmonisation, increasing confidence that findings reflect actual population differences. By including only singleton children aged 4-6 from the majority ethnic group, we minimised the extent to which comparative findings can be explained by differences in age or ethnicity of children between the cohort samples. However, as the Swedish and Dutch cohorts had subnational samples, findings may not be representative of the country as a whole. In particular, GenerationR is from a city with relatively high inequality and poverty in relation to other parts of the Netherlands. 33 Some differences in harmonised variables may also have limited comparisons. Parent education categories were chosen to have a similar social meaning, but were technically different between countries. Using identical categories would have resulted in over 95% of children being in the top two categories in the Swedish and Dutch cohorts. Finally, incomes in the UK, Australian, Swedish and Dutch cohorts were measured after tax; however incomes in the Australian cohort were measured before tax . --- Open access A relationship between income inequality and height has previously been established. In a recent analysis of data from 169 countries, income inequality was shown to be a greater predictor of average height than absolute national income. 34 Our findings also provide further evidence in support of previous studies showing better health among people at all points in the social hierarchy in more equal countries. [11][12][13][14][15][16] To understand the meaning of differences in height between countries and by socioeconomic position, the relative contributions of genetic height potential and environmental conditions need to be unpacked. Although, at an individual level, genetic differences explain the majority of variation in body height, 35 when comparing populations , environmental factors are thought to play the largest role. 36 Population heights have increased over time, alongside improvements in living standards within countries, and height has often been used as a marker of societal living conditions. 37 38 The Dutch population, for example, is now the tallest in the world after an increase in average height of over 20 cm since the 1850s. 39 A number of international studies have shown little variation between populations and ethnic groups in the growth of infants and children from affluent, educated families or when nutritional and health needs are met. [40][41][42][43] This suggests that when environmental conditions are optimal, genetic factors play a limited role in ethnic variations in height. In this study, living standards in the cohort countries vary, and interpreting the relative contribution of genetic potential and socioeconomic differences is complex. Parental height, an important predictor of child height, 44 reflects this complex interplay between genetic and environmental factors. While including it in the analysis would have adjusted for genetic differences, it also would have adjusted for environmental differences that our research sought to identify. There are also complex patterns and inequalities in relation to ethnicity. In the UK, for example, children from Asian and Black backgrounds are taller than white children, despite living in more deprived areas. 28 We therefore analysed the sample from the majority ethnic group only to minimise concerns about differences in genetic potential, and ensure that comparisons reflect environmental differences between socioeconomic groups and countries. There were considerable differences between the cohorts in the country of origin and socioeconomic position of families from ethnic minority backgrounds, as well as health outcomes. Therefore, this approach enabled a clearer focus on the research question, but also resulted in patterns in some population groups not being compared, and may have affected the patterns of inequalities observed. Further research would be useful to identify and compare the extent of inequalities by ethnicity between cohorts from different countries. There are number of potential explanations for a relationship between income inequality and the social gradient in child health. Living in an unequal country may have psychosocial effects on children and their families. Stressors of family life related to living in an unequal country, such as increased mental illness, child maltreatment and long working hours, increased status differentiation and lower social cohesion, are all likely to affect health. 1 More equal countries also often have more generous welfare systems and more equitable public infrastructure, which may influence both population health and health inequalities. 45 46 Other contextual differences between countries, such as gross national income, may play a role, although in work not reported here we did not find a clear relation with social gradients in the study countries. Future research using different data sets and outcomes would enable further exploration of this relationship. In the context of growing income inequality in high-income countries, it is important to understand the implications of income inequality for population health. 47 First, we have demonstrated cross-national variation in the social gap in child height. This suggests that such differences are not inevitable and could be avoided through appropriate policies and interventions. These inequalities in child height are likely to have longterm implications for health and well-being later in life. Second, this analysis provides evidence that children across society do better in more equal societies; although the greatest benefit is among children from less advantaged backgrounds, even children within the most advantaged families may do better in more equal societies. Our findings suggest a picture of multiple, overlapping and interacting socioeconomic contexts . Children Open access in less advantaged socioeconomic circumstances in unequal societies may experience a double detrimentfrom individual socioeconomic circumstances and from living in an unequal country. --- Competing interests TF, VWVJ, JL, HR, LS, AIW and JJM report no conflicts of interest. PKB reports funding from an Economic and Social Research Council doctoral studentship and the Canadian Institute for Health Research . HG reports funding from an ESRC doctoral studentship. KEP reports grants from the ESRC during the conduct of the study, and is co-founder and trustee of The Equality Trust, which campaigns for greater income equality. Patient consent for publication Not required. ethics approval The study involved analysis of secondary data only. All cohort studies had been reviewed and approved by appropriate ethics review boards and obtained informed consent from participants. --- Provenance and peer review

Income inequality and social gradients in children's height: a comparison of cohort studies from five high-income countries.

Introduction The world was shocked when a novel coronavirus disease struck China, specifically the capital of Hubei province, Wuhan in December 2019. Scientists have described it as a novel virus because of its uniqueness compared to previous coronavirus cases. Evidence from the World Health Organisation [1,2] reveals that a few months after the outbreak, the virus had spread beyond Asia to multiple countries around the world, killing over 100,000 people. On March 11, 2020; WHO labelled it a pandemic. By May 11, 2020; the world had recorded 4,013,728 confirmed cases and 278,993 confirmed deaths in 215 countries, areas, or territories. By March 18, 2021; the number of global reported cases and deaths had reached 120,915,219 and 2,674,078 respectively, after 363,691,238 vaccine doses had been administered. Admittedly, the impact of the vaccines and some degree of compliance with COVID-19 protocols remain uncontested, leading to a zero number of cases as of August 7, 2023 [3]. Unlike previous infectious disease outbreaks such as Ebola that stood tall in Africa with a significant and devastating effect, this time around the impact has been less felt in Africa as compared to other regions such as Asia, Europe, and 1 3 America. Several media speculations suggest that if care is not taken, Africa's case will be worse than that of China. That is, Africa may not be able to contain the outbreak if it begins to experience China's intensity and spread. This argument looks plausible owing to the poor health facilities, inadequate public health staff, low-income levels, poor living conditions, high levels of ignorance, corruption, etc., especially in most rural areas. Against this background, several countries and governments in Africa have rolled out COVID-19 national management strategies in line with the WHO's protocols. These include the closure of borders, halting international and domestic travel, the full or partial lockdown of residents, etc. These strategies have not been without associated socio-economic consequences for nations and their citizens. In most poor, lower-income, and middle-income African countries, as much as governments are concerned about the spread of the virus, they are also mindful of the economic impact of their decisions. For example, most African governments have started borrowing, and the average forecasted economic growth rate is likely to hit a record low of negative 5.1% by the close of the year 2020. Millions of people are predicted to start earning less than $1.90 a day, while the trade and agricultural sectors' negative impact is likely to raise food security concerns [3]. In response to possible economic uncertainties, after 3 weeks of the lockdown, specifically April 20, 2020, Ghana is known to be the first African country to have lifted the lockdown in order to ease the economic burden on its citizens. Several other African countries, such as Nigeria, South Africa, etc., also followed suit. Since the lifting of the lockdown, confirmed cases and the number of deaths on record have increased in most African countries. Below is the trend of the COVID-19 confirmed cases in Africa. As shown in Fig. 1, there was not a single confirmed case of COVID-19 in Africa until March 1, 2020. By March 2, Africa had recorded three confirmed cases. Since then, the number of cases kept rising by the day. To curtail the rising number of cases and deaths, on March 21, 2020; Rwanda was reported as the first African country to have imposed a lockdown. After Rwanda, several other African countries also imposed either a partial or complete lockdown. The enormous economic consequences saw most of these countries lift the lockdown, as earlier mentioned. Since the lifting of the lockdown, Africa has experienced a significant rise in the number of confirmed cases and deaths. On July 17, 2020; with Africa's daily increase of 2440 confirmed cases, the highest number of confirmed cases stood at 19,719. Thus, Africa recorded a daily percentage change of 14.12%. As of July 23, 2020; Africa had recorded 642,387 confirmed cases, compared to 1,571,317 in Southeast Asia, 7,948,513 in the Americas, 3,147,860 in Europe, 1,429,084 in the Eastern Mediterranean, and 272,829 in the Western Pacific. Generally, except for the Western Pacific region, Africa would have been touted as having experienced the lowest number of confirmed cases. Nevertheless, what is worrying and calling for compliance is the rate at which confirmed cases keep rising by the day. As of October 31, 2021, the daily increase and total confirmed cases had reached 2065 and 6,151,145, respectively. To halt the rising rate of COVID-19 cases, the development of vaccines and antivirals has become a priority consideration by scientists globally. Nonetheless, in an attempt to leave no stone unturned, classical public health and safety measures have been outlined by the WHO and adopted by most governments in Africa. These measures seek to prevent the spread of the virus while maintaining the livelihoods of the poor and ensuring the resilience of their economies. These measures include the compulsory wearing of a nose mask in public places, observing social distance, washing hands regularly with soap and running water, and so on. Wilder-Smith and Freedman [5] have argued that effective application of public health measures can contain the spread of the virus. Interestingly, while some people have purchased the certified nose masks and are adhering to the directives, for others, we observe a lack of compliance with social distancing, apathy in wearing nose masks, and sometimes ignorantly wearing unprescribed, self-made nose masks that pose health risks instead of providing safety. This present study, which commenced in July 2020, seeks to explain the determinants of COVID-19 public health and safety measures in sub-Saharan Africa. We first generated a unique index that focuses on the public health and safety measures of individuals, public places, and workplaces. Next, the index is used as the dependent variable to investigate its determinants. The paper's contribution is examining factors explaining COVID-19 protocol compliance across 12 African countries. For example, Amuakwa-Mensah et al. [6], used the same dataset from Geopoll and the same number of countries to investigate COVID-19 and people's handwashing behaviour with implications for water use in sub-Saharan Africa . The primary aim of their study was to examine the effect of the level of concern about COVID-19 and handwashing behaviour. The study provided evidence that concern about COVID-19 influences handwashing behaviour in SSA. Likewise, Khalatbari-Soltani et al. [7], have highlighted the need to consider socioeconomic factors to identify the disadvantaged socioeconomic cohorts in addressing potential COVID-19 risk factors. In this light, Philbin et al. [8] and Dwyer et al. [9], have shown a gender disparity gap in COVID-19 management practices. Similarly, Baye [10], used the Demographic and Health Survey of Ethiopia to investigate factors that drive COVID-19 prevention measures in Ethiopia. Using a descriptive approach, the study observed that, apart from the wealthy and mainly urban dwellers, most households are characterised by poor water quality, sanitation, and hygiene conditions. All else being constant, we can infer that wealth and urban factors are associated with a higher probability of complying with COVID-19 preventive protocols. This finding somewhat corroborates the conclusion by Qi et al. [11], that people with higher incomes are more likely to engage in preventive healthcare behaviour. Other studies have also focused on the role and trust in institutions in driving preventive behaviour and mortality. For instance, Oksanen et al. [12], posit that institutional trust is an important factor that is associated with lower rates of COVID-19 mortality in European countries. Likewise, Han et al. [13], used a representative sample of 23,733 from 23 countries to show that higher trust in government significantly influences the adoption of health behaviour. After the introduction of vaccines, a myriad of studies has been conducted to ascertain the potency and impact of the vaccines on patients and potential patients. In Watson et al. [14], they concluded that "COVID-19 vaccination has substantially altered the course of the pandemic, saving tens of millions of lives globally. However, inadequate access to vaccines in low-income countries has limited the impact in these settings, reinforcing the need for global vaccine equity and coverage" . In the absence of equity and coverage, behavioural adjustment is a critical management option to consider. In the present study, we acknowledge the paucity of related studies and attempt to contribute to filling the existing gaps on protocol compliance in the literature. --- Methods --- Data and survey procedure In such a pandemic, it will be highly unethical to constitute a team of fieldworkers to undertake fieldwork, irrespective of the motivation. Thus, several data-driven empirical studies have relied on online surveys using structured questionnaires during such periods. Given time and cost constraints, this study relied on Mobile Accord's representative sample survey dataset, collected from April to May 2020. The first-round dataset was collected between April 2 and April 9, 2020; while the second-round dataset was collected between April 24 and May 2020. Twelve countries from sub-Saharan Africa, namely Benin, Côte d'Ivoire, Democratic Republic of the Congo, Ghana, Kenya, Mozambique, Nigeria, Rwanda, South Africa, Zambia, Tanzania and Uganda were used. The country selection is based on data availability in both rounds of the data collection process. Although SSA comprises 44 countries, 12 are used based on data availability. Hence, these countries are used to represent the entire SSA, which, based on the survey weighting, has been described by Geopoll as representative and can therefore be generalised. It is important to acknowledge the potential statistical skewness within the 12 countries; nevertheless, this skewness also reflects a reasonably diverse statistical distribution, thereby implying that conclusions drawn from these countries might effectively capture regional perspectives. GeoPoll reports that the respondents self-administered the questionnaire. It presupposes that recruitment was not based on compulsion but on choice. Hence, voluntary responses were obtained during the survey. According to the number of questions reported on their website, about 27 were administered. These included questions on concerns about coronavirus, preventive practices , food and security issues, consumer behaviour, trust 1 3 in the government's ability to handle the virus's spread, and the respondent's demographic characteristics. The main source of data for this study is GeoPoll. 1 Details of the variables are presented in subsequent sections. --- Empirical strategy This study uses preventive practices as management strategies or safety protocols/practices. This is done by aggregating the six preventive strategies identified in the dataset to form a unique variable called the preventive practices index. The index's components are social distance, hand washing, working from home, increasing personal hygiene, avoiding public transport and avoiding public places. Given that the dependent variable is binary, we present a pooled cross-sectional logit model. This is estimated together with its corresponding predicted margins . In line with Amoah and Addoah [15] and Amoah et al. [16], the logit model is represented as Eq. 1: where the outcome variable represents the probability of engaging in COVID-19 preventive behaviour. This preventive behavioural variable does not measure what one seeks to do or intends to do, but what the respondent actually does. If the respondent engages in COVID-19 preventive behaviour, it is coded as 1; otherwise, 0. All six possible preventive measures were first aggregated and re-constructed as an index to represent a composite measure of preventive management protocols or practices. Following Galasso et al. [17], and Hughes and Amoah [18], the average index is computed as Eq. 2: This average composite index appears as a dummy variable, where one means adhering to preventive management practices while zero means otherwise. Again, X represents a vector of independent variables. This includes the age of the respondent, which is expected to influence behaviour. In social science literature, this is commonly used to measure experience. Older cohorts with much experience in life may have different expectations relative to younger cohorts, who can easily influence their behaviour. A priori, we expect that older people with much experience regarding the impact of various pandemics and epidemic outbreaks in Africa and their impact on life will be very compliant with COVID-19 preventive measures. Generally, older people have been observed to be more vulnerable and are prone to a higher risk of severe COVID-19 disease relative to younger people. Again, this study included a measure of economic concern as an independent variable. The variable measures the extent to which people are concerned about the expected economic impact of the COVID-19 pandemic on businesses and lives . The responses were ranked from not concerned to very concerned. As expected, respondents who are very concerned that the impact of the pandemic would be devastating are expected to change their behaviour to influence members of their households. On the other hand, respondents who have not yet felt the impact or expect any impact on their households may not be concerned; hence, they may choose to be indifferent or not comply with the preventive measures. Gender differences matter when making choices; hence, gender is included as an independent variable. Gender plays an important role in shaping preventive healthcare behaviours . The empirical literature has shown that, on average, females or women are more risk-averse in their decisions while males or men are more risk-loving. This variable is important because engaging in preventive behaviours shows that how a person is concerned about the risk of being infected or dying because of exposure to coronavirus. Based on the disparity in gender tendencies, we expect that women will engage more in preventive behaviours than men. Here, respondents were voluntarily made to indicate their gender, of which males and females were coded as one and zero , respectively. Also, practical experience is one of the ideal ways to acquire first-hand knowledge about behavioural differences. Lessons like this cannot ordinarily be taught except through practical experience. For example, it will be extremely difficult for a patient's pain to be holistically appreciated without experience. This variable was obtained after the respondent indicated that he or she had tested positive for COVID-19 or otherwise. Those who tested positive were coded as 1, while p preventive behaviour index y = 1|X = f 0 + 1 X X = 1 n n ∑ i=1 x i = 1 n x i + ⋯ x n those who tested negative, not sure, or not tested were treated as otherwise and coded 0. We expect that those who have tested positive will engage more in preventive behaviour as compared to the others. Another variable of interest is the interaction between those who have tested positive and gender. Thus, we expect that risk averse respondents who have tested positive will be highly inclined to engage in preventive behaviour as compared to risk-loving respondents who have tested positive. Geographical location influences a person's level of exposure, perspective, taste and preference or choice. From a theoretical perspective, we expect people who have had much exposure and a broader perspective of activities and opportunities to make choices that are different from those with a narrower perspective. In this study, respondents who are geographically located in urban areas are contrasted with those who reside in rural areas. Generally, rural residents are believed to have a narrower perspective on modernity and current developmental issues as compared to urban residents. In this study, we expect urban respondents to be associated with a higher probability of engaging in propreventive behaviour relative to rural respondents. The role of institutions in behavioural choices cannot be overemphasised. According to North [19], institutions shape human interactions and their behavioural strategies or choices. We define institutional quality as those systems that seek to improve effectiveness and efficiency in society. Strong institutions are expected to hold humans illegitimate or unprofitable choices in check for the betterment of the whole society. So, we considered trust in financial institutions as a driver of COVID-19 preventive practices. That is, if the financial sector demonstrates their support to both the government and the private sector by complying with the moratorium request as well as financially supporting the private sector in the production and supply of PPE kits and other needs, these essentials will be readily available on the market for easy access. However, where the financial institutions are not supportive, access to PPE kits and other needs will be difficult and expensive due to scarcity, which can easily discourage most Africans because of their lower income characteristics. The role of government and political will is very important in making societal decisions that seek to influence individuals' behaviour. In addressing COVID-19 challenges, most of the decisions made by government appear like a doubleedged sword. In one breadth, it may end up undermining the rights and liberties of individuals, while in another breadth, it has the overarching aim of seeking the interests of the entire society. Such crossroads decisions require a bold and courageous government that, regardless of political pressure from opposition political parties and voters, will be consistent and push the entire society's interests over the interests of the teary few. Here, we expect that respondents who have seen the achievements of the government, in addition to what it is capable of, will repose their trust in him. Such a trusted government can easily influence the preventive behaviour of the populace. Besides, through the government's role, subsidies can be made available to the private sector to increase the supply of PPE kits, which will promote access and compliance with COVID-19 preventive protocols. Another institution that plays a key role in ensuring the protection of the minority is the Non-Governmental Organisations . In this study, we included this variable in the model to ensure that no one is left out in the spread of COVID-19 preventive measures. By expectation, the more NGOs we have, the more people will be educated through advocacy to use PPE kits and comply with preventive protocols. Lastly, in as much as the public sector is observed to play an important role in Africa, averagely, the private sector is relatively bigger as it employs about 55% of working age individuals, 90% of available jobs, and accounts for 80% of total consumption . We expect the private sector to play a key role in promoting demand and supply of PPE kits, which will facilitate compliance with preventive measures. --- Summary statistics of modelling variables From Table 1, the outcome variable is an average measure of all six preventive management protocols or practices. The index is constructed as the average of the six sets of dummy variables following Galasso et al. [16], and Hughes and Amoah [17]. This average composite index was defined to equal one if the index is above 0.5 and zero if otherwise. This appears as a dummy variable where one means adhering to the preventive management practices while zero means otherwise. The mean value of 0.72 and a median of one suggest that a significant proportion of the respondents religiously abide by the protocols. An estimated 46%, 42% and about 88% of respondents trust that the NGOs, private sector and Government, respectively, are responsible for providing assistance during the COVID-19 pandemic. About 71% do not trust the role of the financial sector. Eco has a mean of 4.29, which suggests that on average, respondents are highly concerned about the economic impact of the COVID-19 pandemic. The sample constitutes about 55% males and 45% females. Out of this, about 10% indicated that they tested positive, while the majority, constituting about 67% are urban dwellers. As one would have expected, the sample looks very youthful, with an average age of about 31 years. --- Diagnostic test Given that the variables used for our modelling contain several demographic, institutional and country-specific variables it is expected that some of the variables, will themselves correlate. Now, the presence of such correlations may lead to multicollinearity. This problem makes it difficult to ascertain the effect of an individual variable on the outcome variable. To test for the presence of this problem, we used the pairwise correlation test and found that the highest degree of correlation coefficient of approximately 72% exists between NGO and private, while the lowest correlation coefficient of 0.04% also exists between gender and private. Against this background, NGOs and private companies are not estimated in the same model. Model 1 of Table 3 included NGO, while Model 2 included private companies. That is, we do not expect severe multicollinearity challenges in our modelling; hence, the results are valid on this score. Next, we included country-specific dummies to control for the differences in the random error term across the different countries adhering to COVID-19 protocols. Then again, to deal with community-level correlations in the random error term, we clustered the standard errors at the primary administrative level. This seeks to ensure that inherent correlations in the random error term of the rate at which respondents complied with the safety protocols within the same community are addressed. That is, we do not expect severe heteroskedasticity concerns in our modelling, and we are confident that our estimates are valid on this score. In order to further ensure that our model is properly identified, we used the Wald chi-test to find out whether the explanatory variables significantly explain the outcome variable. With highly statistically significant results, we conclude that the explanatory variables together explain the COVID-19 management protocol index and that their coefficients are not equal to zero. --- Results and discussion A traditional factor that promotes preventive healthcare utilisation is the respondent's experience over time. According to Amoah and Addoah [15], a person's age can affect his cognitive capacity to recall experiences. All other things being equal, older cohorts are more likely to recall many past life-ending epidemics than younger cohorts. Similarly, older people, especially those with multimorbidity, appear more vulnerable and stand a higher risk of severe COVID-19 disease than younger people . Based on this, we expect older cohorts to engage positively in COVID-19 preventive protocols. However, the contrary is found. We have evidence of a negative and statistically significant relationship between the age of the respondent and COVID-19 preventive protocols. That is, relative to the younger cohort, older people are less likely to engage in COVID-19 preventive protocols. The associated coefficient of the marginal effect obtained is 0.0020. This suggests that, if age increases by one year, the probability that a respondent will engage in COVID-19 preventive protocols will decrease by 0.20%. This finding is counterintuitive yet plausible. By explanation, first, given that older people are more vulnerable to severe COVID-19 disease and its associated consequences, they are more likely to stay away from COVID-19 hotspots or highly infectious environments and activities than the younger cohort. Second, it can also be argued that access to credible information from credible institutions regarding the data, causes, effects, and preventive measures of COVID-19 is very pronounced on technologically driven platforms. Available data shows that in 1999, as few as 11% of Africans had mobile phone coverage ; however, this had risen to 60% by 2008 . Indeed, with technology, the younger, technologically savvy cohorts, the youth, or 'digital natives' , are privy to more information that drives their behaviour than the older cohorts. Relative to the younger cohort, information is asymmetric among the older cohort, hence their lower likelihood to engage in preventive practices. One of the impacts of COVID-19 has been on the output of economies , and an import-driven continent like Africa has not been spared. That is, all else held constant, the negative shocks to the manufacturing world will trickle down faster than expected to hurt the economies of Africa. The OECD [24] explains that, for the global economy, the impact of the COVID-19 pandemic will cause a negative shock to the supply of goods and services, which in effect will force many factories to close down, thereby unsettling global supply chains. During the lockdown, most African countries relaxed the lockdown for economic reasons. Against this background, this study seeks to ascertain whether individuals' concerns regarding economic repercussions will exert a constructive influence on their adoption of preventive behaviours. Here, the respondents were asked to rank the extent to which they are concerned about the economic impact of COVID-19. We expected that those who have been severely affected would indicate that they are 'very concerned' , while those who have been less affected would indicate that they are 'not concerned' . Using 'not concerned' as our reference category, we have evidence of a positive relationship for all categories, with concerned and very concerned' being statistically significant at 1% and 5% levels, respectively. In much more detail, relative to those who are 'not concerned', those who are 'concerned and very concerned' are associated with a 4-9% probability of engaging in COVID-19 preventive management practices. This evidence is consistent with Amuakwa-Mensah et al. [6], who posited that concern influences behaviour. Consistent with expectations, gender is negative and statistically significant. The associated coefficient of the marginal effect obtained is -0.0169. This suggests that being a male relative to a female decreases the probability of engaging in COVID-19 preventive protocols by 1.69%. The plausibility of this finding is underscored by the fact that, generally, females are relatively risk-averse and are more likely to engage in preventive measures than males . This evidence contradicts some of the risk-taking-related studies that found males to be relatively more risk-averse and more willing to spend to avert risk [15,26,27]. Admittedly, these authors explain that their results could be explained by the household social and economic responsibilities of the males in the study areas. Interestingly, these opposing views have been upheld by Nelson [28] who argues that gender effects are ambiguous and overlap. It is also important to mention that, in some instances, no statistically significant gender effect is found . Contrary to expectations, those who tested positive were found to be statistically insignificant. Indeed, people who reported to have tested positive were perhaps under quarantine, and thus they did not consider the outlined preventive practices necessary under quarantine. To better understand the gender differences with respect to respondents who have tested positive, we found a negative and statistically significant relationship. We report a marginal effect of -0.0539 for the interaction between gender and test. This means that, relative to females, if positive-tested males increase by 1%, COVID-19 preventive management practices will decrease by approximately 5%. That is, relative to females who have tested positive, males who have tested positive are associated with a lower probability of adhering to COVID-19 preventive practices. This is justified by the fact that females are observed to be risk-averse and would want to comply with the preventive practices more religiously than their male counterparts. Several studies have shown that urban residents are more likely to be associated with certain preventive health services than rural residents. That is, geographical location plays a crucial role in one's ability to engage in preventive healthcare practices. The results show a positive and statistically significant relationship between urban location and COVID-19 preventive management protocols. The reported marginal effect is 0.0226 for urban geographical locations. This suggests that, relative to rural areas, being in an urban area is associated with a 2.26% increase in the probability of engaging in COVID-19 preventive management protocols. Institutions and their readiness to provide the needed support are very important for quality preventive healthcare delivery. Given the absence of data on access to quality preventive healthcare delivery, we used other measures of institutional quality in the respective countries. The first institution considered is the financial sector because of its expected supportive role in the PPE supply chain. Respondents were asked if they trusted the commercial banks to assist during the outbreak of COVID-19. This is used as a proxy for institutional quality, following Wang and Gordon [31]. Our finding shows a positive and statistically significant relationship between trust in commercial banks' ability to assist during the period of the COVID-19 outbreak and COVID-19 preventive management practices. With a marginal effect of 0.1095, it suggests that those who trust in commercial banks' ability to assist are associated with an approximately 11% probability of engaging in COVID-19 preventive management practices. By implication, this study has revealed the impact of commercial banks activities in promoting COVID-19 preventive practices in Africa. Another institutional variable included in the model is the role of government. This is considered relevant as it examines the role of government in societal decisions towards engaging in preventive management practices. We have evidence of a positive and statistically significant relationship between trust in the government's assistance to society during the period of the COVID-19 outbreak and COVID-19 preventive management practices. We report a marginal effect of 0.0097, which implies that those who trust in the government's ability to provide the needed assistance during the pandemic are associated with approximately a 1% probability of engaging in COVID-19 preventive management practices. This finding acknowledges the impact of the government's role on human behaviour towards promoting COVID-19 preventive management practices in Africa. Most NGOs in Africa can be described as the bridge between the high/rich and the low/poor. Their role is important in promoting equitable distribution of scarce PPE kits and other essentials for survival. This study finds a positive and statistically significant relationship between trust in NGOs for providing the needed assistance during the COVID-19 pandemic and preventive management practices. From the marginal effect estimates of 0.0461, it implies that those who trust in the NGO's ability to provide the required assistance during the pandemic are associated with an approximately 5% probability of engaging in COVID-19 preventive management practices. Our result provides evidence that those who trust the NGOs believe that they have generally been involved in promoting preventive management practices in Africa. In Africa, most of the NGOs are privately owned. Thus, we suspected a possible collinearity between NGOs and the private sector. A pairwise correlation test undertaken shows a correlation coefficient of approximately 72%. Hence, we estimated model 1 by including the NGOs and model 2 with the private sector's assistance. Similar to the NGO results, we have a positive and statistically significant relationship between trust in the private sector's assistance during the pandemic and COVID-19 preventive management practices. The results show a marginal effect estimate of 0.2511. That is, those who trust in the private sector's role in providing the expected assistance during the pandemic are associated with an approximately 25% probability of engaging in COVID-19 preventive management practices. This result also lends support to the expectation that the private sector has positively impacted preventive management practices in Africa. The method of computing a simple arithmetic average of a binary response may not capture the overall weight that respondents put on each individual component. Hence, an alternative approach is to use Principal Component Analysis , which is widely used for generating indices. Specifically, the PCA is a method used for generating a composite index from a set of different components . For example, with all the various preventive measures for COVID in the dataset, it is possible to use PCA to generate a composite index that represents the overall preventive strategies of a respondent in the dataset. As part of validating the pooled cross-sectional logit results of the study, we used the PCA results in Tables 4 and5 and found that, following the eigenvalues, the highest value, which is component one, has a proportion of about 0.24. The next highest component is component two, with a proportion of about 0.21, followed by component three in that order. This implies that about 24% and 21% of the variations are accounted for by components one and two, respectively. We admit that these are not as high variations as one would have expected. Indeed, they are not high yet informative enough for our purpose. So, we further estimated the predicted values of the component to obtain a continuous variable. Now, the predicted variable is used as our dependent variable, while the same covariates are used to investigate the robustness of our model. Unlike the logit model, this time we investigate the relationship using the pooled ordinary least squares method. The results, as presented in Table 5, provide evidence to support our earlier findings vis-à-vis the signs and significance that our results are robust across the different techniques. --- Robustness checks We start with age, as in the earlier case. The results in Table 6 show evidence of a negative and statistically significant relationship between the respondent's age and COVID-19 management practices. The results based on the concept of experience are counterintuitive because our study suggests that as people age, their willingness to engage in COVID-19 preventive practices declines. This is consistent with our earlier results. Again, in line with our earlier results, respondents who are "very concerned and concerned" about the economic impact of the COVID-19 pandemic are more likely to engage in COVID-19 management practices as compared to those who are unconcerned. Similar to our earlier results, an interaction between gender and those who have tested positive was found to be negative and statistically relevant in driving COVID-19 management practices. That is, relative to females, male respondents who have tested positive are less likely to engage in COVID-19 management practices. Also, akin to our earlier finding, urban areas exhibit a positive relationship with engaging in COVID-19 management practices, though irrelevant in this case. Unfortunately, the study is unable to explain why the robustness evidence has the right sign yet has failed to converge in statistical significance. Moreover, we expect the financial sector to support PPE businesses during such pandemics. Analogous to our earlier evidence, trust in financial institutions has a positive and statistically significant effect on COVID-19 management practices. Likewise, the role of government in such difficult times is very crucial. This consistently exhibits a positive and statistically significant effect on COVID-19 management practices. The results from NGOs and the private sector align with what we had estimated before. Thus, both results show a positive and statistically significant estimates. Thus, the role of NGOs and private firms is found to drive COVID-19 management practices in Africa. Overall, we show overwhelming evidence that the results in Table 3 have been validated to a very large extent by the results in Table 6. people who tested positive is found not to be relevant in both models, being in an urban area relative to a rural area is found to be positive and statistically significant for females but not for males. That is, females in urban areas are more likely to comply with the index, however, this is immaterial in the case of males. Also, relative to lower levels, higher levels of economic impact are found to drive the index. This evidence is statistically significant and corroborates our earlier results. Furthermore, the Wald chi-test is used to examine gender disparity across variables in the model for the Index. The results as presented in Table 7 show that, given the independent variables, gender disparity alone is irrelevant in explaining the COVID-19 management protocols . --- A test of disaggregated COVID-19 management practices by gender Here, we use both parametric and non-parametric tests to examine how the effect of disaggregated COVID-19 management practices vary across gender. The evidence from Philbin et al. [8] and Dwyer et al. [9] suggests that we should expect gender-disparity in COVID-19 management practices. However, what is unknown is whether the protocols together as a composite or individually exhibit gender-disparity. First, in Table 8, our results show that there is a statistically significant relationship between females and males in avoiding public transport in line with COVID-19 management practices. This implies that differences in gender play a role in the decision to patronize or avoid public transport during the COVID-19 pandemic. Averagely, males are more likely to avoid public transportation relative to females. This is plausible because, for most African countries with poor pedestrian access to motorable road, perhaps males can easily take the risk by using unconventional means of transport as compared to females. Although further investigation may be needed to explain this further, it is important to point out that males are more likely to take road risk than females . Also, in Table 9, our results indicate that there is no statistically significant difference between females and males in avoiding public places. Thus, the decision to avoid public places is not gender sensitive. This is most likely the case, if your source of socio-economic or health survival is within the context of a public place. In such cases, gender disparity is immaterial. Similarly, Table 10 shows no statistically significant difference between females and males in their choice to work from home. This is intuitively justified on the grounds that, if a firm mandates its workers to work from home, whether you are a male or female, such a decision is made at the firm level regardless of gender. Thus, gender disparity is irrelevant in a firm's decision for their workers to work from home. Besides, in Table 11, we find evidence of a statistically significant difference between females and males in practicing good hygiene. Our results show that, on average, males are marginally more likely to practice good hygiene than females. This is counterintuitive; however, it may sound plausible if the man is the head of his household and bears the cost of practicing bad hygiene , then the man will demonstrate leadership by practicing what he preaches. Again, in Tables 12 and13, our study finds a statistically significant difference between females and males in practicing social distance as well as regularly washing their hands. The evidence suggests that, on average, females are more likely to practice social distance and handwashing than males. The latter result corroborates Amuakwa-Mensah et al. 's [6] finding that women wash their hands more regularly than men. Again, females are more risk-averse than males and would want to socially keep their distance as a risk-averting mechanism. --- Conclusion This empirical study shows that despite the rising trend of COVID-19 cases, the fear surrounding the spread and its impact across the world, especially in sub-Saharan African countries, this empirical investigation reveals a noticeable tendency towards complacency in strictly adhering to all the COVID-19 management protocols as prescribed by governments. Thus, the study sought to investigate the factors that may account for this unusual behavioural response. To achieve this, we used a unique secondary dataset of 12 sub-Saharan African countries and generated a unique index that aggregates six COVID-19 management protocols. The study found that younger people were more inclined to comply with the safety protocols than their older cohorts. Again, people who were more concerned about the economic impact of the pandemic were associated with complying with the protocols. Females who have tested positive were more inclined to comply with the protocols, unlike males. The urban respondents were also found to be more compliant with the protocols than the rural respondents. All institutional variables were observed to play significant roles in influencing the behaviour of respondents in complying with the COVID-19 pandemic management protocols. Further, we investigated gender differences across the disaggregated COVID-19 pandemic management protocols and found that with respect to avoiding public transport, hygiene, handwashing, and social distance, females behave differently in complying with the protocols than males. However, in relation to avoiding public places and working from home, we did not observe significant differences in the behaviour of females and males. In as much as some efforts have been made towards complying with the COVID-19 pandemic management protocols, especially regarding individual protocols, much needs to be done in the call for all the protocols to be adhered to. That is, we acknowledge that a big gap still exists in Africa when it comes to complying with all six COVID-19 pandemic management protocols used in this study. We recommend policies that focus on demographic factors, institutional measures, and country-specific factors to drive compliance with COVID-19 management protocols. Although this study produces valid estimates relevant for policy decisions, it must be acknowledged that it is not without its limitations. For example, the use of an online survey by Geopoll and the number of sub-Saharan African countries used are not without their unique limitations. Nonetheless, it goes without saying that the survey tool used and the number of countries reached at the height of the pandemic are reasonable and could not have been overemphasised. --- Data availability The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request. --- Heterogeneous effect of aggregated COVID-19 management practices index The paper further investigates the heterogeneity of the drivers of our constructed COVID-19 management practices Index. In Table 14 , with the index as the dependent variable, the drivers are again estimated for males and females, respectively. Generally, the results are very similar to the earlier results, as reported in Table 3. To begin with, we have evidence that NGO and Trust are positive and statistically significant for both males and females, with marginal changes in the coefficients. This implies the absence of gender heterogeneity for NGO and Trust. Thus, both males and females believe that NGO and Trust are more likely to provide assistance towards COVID-19 management practices . Further, we observe gender heterogeneity in relation to Government. Similarly, age is negative and statistically significant. That is, the younger cohort is more inclined to practise the protocols than the older cohort. However, this is not sensitive to gender disparity. Again, while the number of Author contributions A. wrote and reviewed the entire manuscript. Funding There has been no funding received. --- --- Appendix See Tables 8,9, 10, 11, 12, 13, 14.

The aim of this study is to examine the factors influencing compliance with COVID-19 preventive management strategies in sub-Saharan Africa (SSA). To address the lack of national data associated with this study, a comprehensive crosssectional panel dataset by GeoPoll, encompassing 12 SSA countries, is used. The study employs a novel index and a cross-sectional pooled logit econometric regression with predicted margins to identify the determinants of behavioural responses to COVID-19 management strategies. The findings reveal that demographic factors, institutional measures, and country-specific characteristics significantly impact compliance with COVID-19 management strategies in SSA. Additionally, a gender analysis of disaggregated COVID-19 pandemic management protocols revealed that females exhibit different compliance behaviours compared to males, specifically in relation to public transport, hygiene practices, handwashing, and social distancing. However, no significant gender differences are observed in behaviours such as avoiding public places and working from home. Surprisingly, the composite index, which measures overall compliance with all protocols, does not demonstrate any gender differences. Based on the findings, policies aimed at enhancing compliance should consider demographic, institutional, and country-specific factors while also accounting for gender differences in specific compliance behaviours.

INTRODUCTION Despite several decades of development projects in Aboriginal and Torres Strait Islander communities in Australia, few have been systematically evaluated or monitored . As a result, there is limited knowledge about what works and why. This undermines accountability to Aboriginal people and other stakeholders . In recent years, Aboriginal people have increasingly called for a greater focus on monitoring and evaluation to improve the quality of programs and increase Aboriginal people's control over their own development . Evaluative enquiry with Indigenous Australians -especially those living in remote Australia -poses unique challenges. This includes the need for appropriate data collection methods and culturally sensitive engagement with Aboriginal people . More fundamental are considerations about how evaluation practice with Indigenous people should address the different worldviews of Aboriginal and non-Aboriginal people . To some degree these views echo the long term discussion about the epistemology of evaluation practice and the limits of positivist approaches in assessing programs in complex development contexts . It is also linked to discussions of the limits to counterfactual logics versus more configurational and generative logics . Program monitoring is an embedded system of judgement that underpins the overall assessment process. Given the dynamic and context specific nature of many programs designed to support Australian Aboriginal development, monitoring from project commencement is an important contribution to relevant and informed program evaluation . This paper reports on initial work undertaken by the Northern Land Council in northern Australia to develop a monitoring system which privileges and builds from Aboriginal Australians' own vision for the development of their communities. --- BACKGROUND The Northern Land Council is a statutory organisation responsible for assisting Aboriginal people in the northern region of the Northern Territory to acquire and manage their traditional lands and seas . While they are strong in language, culture and connection to country, two thirds of Aboriginal people in the Northern Territory live in regional and remote communities and outstations where they experience disadvantage in terms of their social, economic and health status . The NLC seeks to achieve better outcomes for its 36,000 constituents through Aboriginal-led development. The NLC Community Planning and Development program works with Aboriginal landowner groups to support them in using royalties or rent money from land-use agreements to undertake projects that create lasting community benefit . The CP&D program uses a community development approach, with projects governed and managed by Aboriginal groups. In addition to delivering tangible benefits to Aboriginal groups, the CP&D program also aims to strengthen and build the capabilities of groups and communities to manage and govern their assets. A core assumption of the program is that more cohesive groups, which are better able to make decisions collectively and manage their own resources effectively will have enhanced agency and control. The community development work which is the focus of this report commenced in 2017 as part of the development on an indigenous land use agreement for Project Sea Dragon, a large-scale prawn farm at Legune Station, a pastoral lease near the border of Western Australia and the Northern Territory. Although at the time of writing the project was still awaiting financing, ILUA milestone payments have been made to the Djarrandjarrany Native Title Holders and other Native Title Holder groups on whose land the proposed prawn farm will be built. 1 Given the potential for this to be a 99-year project, the NTHs elected to use a percentage of the milestone payments for the benefit of the broader community. To this end, they sought the support of the NLC CP&D program. In 2018 the NLC CP&D program received Federal government funding to undertake a three year monitoring and evaluation system project, including employment of a 0.8 FTE monitoring and evaluation project officer commencing in 2019. NLC were seeking to expand on the day-to-day judgements about the projects and make better use of monitoring to support their community development approach. Importantly, they were interested in monitoring systems which provided accountability to Aboriginal people. The Federal government funding provided an opportunity to experiment with different monitoring approaches in order to identify an approach that would support the aims of the CP&D work. The proposal was to trial three different monitoring approaches, and to use the learning from this to both establish a comprehensive and appropriate monitoring system for ongoing work and to generate learning about effective monitoring which could be shared more widely with other organisations working with Aboriginal people in the Northern Territory and beyond. The three different approaches were designed to approach the task of monitoring from different directions. They included a 'traditional' monitoring approach, which utilised data collected as part of program implementation to assess progress against the project outcomes ; a locally led approach utilising Aboriginal people's perspectives and assessment of the community development projects and their benefits ; and a third approach focused on monitoring of well-being, going beyond a focus on the specific project. This paper reports on the development of the third approach, which was undertaken through collaboration with Djarrandjarrany NTHs. --- THE MONITORING APPROACH Djarrandjarrany NTHs call the monitoring system 'Checking up to keep on track'. Several considerations shaped the approach. The first was the 'direction' of the monitoring. Typically monitoring focuses on the program or project, collecting information or evidence about activities and then proceeding through an analysis process to make a judgement about the progress and value of that project. This approach, looking from the 'project out', privileges the value of the intervention and its likely contribution to change . A different approach -one which is more appropriate for some complex development programs, including those focused on Indigenous people -is a context centred approach . This approach starts with examining what has changed for people and then looks at the relative contribution of the project to that change. A further influence on the approach was alignment to the long-term goals of the NLC CP&D program, namely, to support Aboriginal people to have enhanced agency and control. Utilising a critical approach to monitoring , the focus was on providing people with information about their situation in a way that supported them to make further judgements and act within and on that situation. Finally, the approach was influenced by approaches developed elsewhere in Australia. In particular, it drew on work undertaken with Yawuru people in Western Australia , which demonstrates the value of supporting Aboriginal people to define their own intended outcomes and then systematically monitor progress towards those outcomes over time. The aim was to generate information that would resonate with Aboriginal people and support their knowledge about areas that they defined as significant for themselves and their location . Earlier discussions with the NTHs indicated that they had a strong interest in knowing how the community development work would support overall community health or 'wellbeing'. The concept of wellbeing has received increased global attention in recent years, and there is considerable debate about its definition and measurement . For Indigenous peoples' wellbeing is a holistic concept encompassing mental, physical, cultural and spiritual health. It is "steeped in the harmonised interrelations that constitute cultural well-being, including spiritual, environmental, ideological, political, social, economic, mental and physical factors" . When the NLC CD&P team worked with the NTHs to identify the long-term changes they were seeking, their vision suggested a holistic focus, a focus with several features coming together to represent the health or wellbeing of people in that location. Features included: • Healthy and happy . • Teach country and culture to your people and language and bushfood. • Education and schooling and transport. • Running the community ourselves -strong leadership. • Running our own businesses. • Employment; for example, jobs fixing the homeland community ; rangers; gardening/nursery. • To be recognised as Native Title Holders, so we can make decisions for country • Kids looking after country in the future. • Living on country at Marralum. Based on these findings, mindful of the long-term CP&D intention of increased agency, and drawing from experience elsewhere in Australia , a Family Well-being empowerment framework was utilised as the starting point for developing the monitoring approach. FWB is well documented as a tool for engaging Aboriginal Australian adults in reflecting on and taking greater control of their health and social and emotional well-being . The tool enables people to develop greater awareness of, and language to articulate, their emotional, spiritual, mental, and physical needs through a narrative group work approach. With such awareness people demonstrate strengthened personal and community capacity to meet these needs . 2 --- RESEARCH DESCRIPTION In the following sections we describe the process through which the Djarrandjarrany NTHs identified the outcomes or domains of change they wanted for their communities that would become the focus of the monitoring. We then describe the process of developing an approach to measure change in these domains. Throughout the process we were guided by the National Health and Medical Research Council's 'Ethical Conduct in Research with Aboriginal and Torres Strait Islander Peoples and Communities' which provides a set of principles to ensure research adheres to six core values: spirit and integrity; cultural continuity; equity; reciprocity; respect and responsibility . Ethical approval to undertake the work was provided by La Trobe University. The team developing this approach included NLC CP&D staff with backgrounds in community development, land management, cross-cultural engagement and governance and established, albeit relatively new relationships with NTHs. This was complimented by skills and experience in Family Well-being, monitoring, research and evaluation brought to the team by research partners at La Trobe and James Cook University. --- Identifying domains of change As discussed, NTHs had already identified wellbeing -defined in a holistic sense -as a key concern. These ideas were further explored through workshops held in Kununurra in Western Australia and Wadeye in the Northern Territory in June and September 2019. Twenty-five NTHs participated; 14 women and 11 men. When asked whether they would prefer to run the workshops in local language, with translation for those who attended from outside the community, participants stated they were comfortable using English. The workshops involved 3 main components: defining key concepts, identifying domains of change that were of value to them, and measuring change. The workshops opened with a discussion of guidelines for how the group would work together and the nomination of a TO as Chair to ensure these were followed. As monitoring and evaluation was a key focus of 2 FWB was initially designed as a 5-stage group program where students undertake six months equivalent of full-time training and obtain a Vocational Education and Training Certificate II-level qualification. However, the program has been adapted as a short course where students explore the topics of human qualities, basic human needs, life journey, relationships, conflict resolution, emotions, crisis, grief and loss, and beliefs and attitudes . this project, and an essential component of the NLC CP&D support, a first step involved ensuring that NTHs were clear about the meaning and relevance of monitoring for them. The NTHs agreed that taking notice of what was happening and checking with each other how things are going was important and expressed interest in exploring how best to undertake monitoring in ways that helped them to improve health and well-being. NTHs likened monitoring to checking the washing machine or checking the tide and adopted the term "checking up to keep on track' for the monitoring process. Topics from the FWB tool were then used to engage the NTHs in a reflective yet structured conversation on domains of change. This was facilitated by one of the authors who has training and extensive experience using the FWB framework. Given their clear alignment with the domains the NTHs had previously identified, attention was given in the workshops to the FWB topics of Leadership Qualities, Basic Human Needs and Managing Relationships. In the topic, 'Leadership Qualities' NTHs were asked to identify someone they considered to be a leader in their community and to share ideas about the qualities required for fostering community and personal leadership. In the 'Basic Needs' topic, NTHs discussed their physical, mental, emotional and spiritual needs and ways in which these could be better met for themselves and the community. In the 'Managing Relationships' topic, NTHs reflected on the processes and qualities associated with different relationships, including those where there was tension or conflict, those that were more conciliatory and those that are 'heart centred' and promoting of love, wisdom and compassion. For each of these topics participants' comments were recorded on large sheets of flipchart paper attached to the walls of the room. Detailed workshop notes were taken for each of the four workshops to document the workshop processes and the TO conversations. These notes included some direct quotes from NTHs as well as photographs of the flipchart paper and of the participants. These notes formed the data for analysis. --- Data analysis Consistent with the NHMRC ethical principles and the ethics of care and responsibility embedded in Aboriginal research methodologies we sought to take a culturally safe and respectful approach to data analysis in which we privileged Indigenous knowledges and cultural traditions . Theoretically we were informed by constructivism which allows for multiple realities, the influence of contextual social processes and structures, the relational nature of research and the subjective position of the researcher . The initial analysis -undertaken by one of the authorsfocussed on the words of the NTHs and aimed to understand the priority domains of change for them. Using thematic methods , the notes were collated into one document to enable careful reading and line-by-line coding. Emergent codes were grouped into analytic categories. Three major themes emerged from the analysis. The first centred on the qualities required for effective leadership, including values and skills. The second theme addressed elements of social and emotional well-being, with a strong focus on connection to culture. The third theme captured broader issues including safety, education and life-long learning, and employment. As the author who undertook the initial analysis was not Indigenous, the analysis was verified by NLC staff and by the NTHs at subsequent meetings. The results of the analysis are presented below, with participant quotes provided as supporting evidence. These quotes arose from workshops conducted in Wadeye and Kununurra in 2019.As these quotes were documented as workshop notes, there is a small risk they may not represent the spoken words exactly. --- FINDINGS --- Leadership qualities Strong leadership was considered vital to well-being. The NTHs agreed that they have some strong leaders, but they need more role models. The reflective FWB conversations on human qualities generated a long list of the values and skills that effective leaders have. Most commonly identified were the qualities of being caring, compassionate and kind: "Be kind and humble with open arms". People spoke of caring for their children and other family and community members: for example, one woman was "looking after an Aunty who was unwell, helping to meet her physical and mental needs". Another participant noted that it was also important to care for country. Respect was considered an essential leadership quality: "Everyone needs to be modelling respect". This involved both self-respect and respect for others: "need to respect yourself and show you kids respect". Participants noted that respect was the basis of a community song -the Kununurra respect song, "Just be proud". Also mentioned was discipline which involved being trustworthy and responsible, hard work and being on time. In Wadeye NTHs spoke of the importance of listening, "doing things for other people", being "kind and humble", having "open arms", taking responsibility, being inspiring, hard-working, and taking a background helping role. One person thought "Being organised, keeping a clean and orderly house" was important. NTHs also felt that leaders needed to have the skills to make things happen. Most important were communication skills. People discussed how the work occurring at Legune required a large group of people to work together to make decisions. As NTHs they needed to "speak up"; and "be bold and communicate, be brave, support and direct". They needed to know how to chair a meeting and deal with conflict. This was not always easy for everyone to do; one woman said that "she would like to get more confidence, she is working on it, but she is a bit shy". --- Social and emotional well-being Physical and mental health Having a health clinic, exercise, healthy eating and giving up smoking were identified by participants as basic physical needs during FWB conversations in both Kununurra and Wadeye. Mental health was also a priority for participants. The high rate of suicide was a serious concern and people felt more needed to be done to reduce this. People spoke of the need to attend to their own mental health: "If you are not feeling well spiritually, go to your next-door neighbour, listen to music, water your garden". Some sought professional help, "to let our feelings out" and thought it important that others feel able to do this. Several women spoke of the need to address unhappy personal issues, including family relationships: one woman had left a partner who had bullied her, and she was now in a healthier relationship. --- Connection to culture Connection to culture was viewed as essential for social and emotional well-being and featured heavily in FWB discussions. One person reflected: "Culture is one of the most important things for keeping people on track. Culture is everything". Connection to culture involved knowledge of language, totem and history, story-telling and singing in language, staying on land, dancing in corroboree, and connection to other clans. Participants expressed concern and sadness at what they perceived as a loss of culture: "people are not going to corroboree… some of the totem and culture has been lost, old people are losing voice and energy. It's sad to lose the culture.". Participants discussed the importance of cultural leadership and sharing and teaching young people about culture at length. They spoke of the need to teach young people about their culture so that they "know where they come from [and have] connection to culture and land". The group shared some stories about cultural leaders including a grandmother who would shoot goanna from the front seat of the car or go out digging with crow bars and how she shared culture and kept people safe. One woman was "learning how to teach language so can be a teacher of languages to meet mental needs". Spending time on country was vital for teaching culture; "Family time out bush is important". --- Broader issues Community safety Community safety was identified as a basic need and an indicator of well-being. It involved safety within both houses and neighbourhoods. Within the house participants discussed the importance of child safety. This involved parental supervision of children's "coming and going" and their internet use. They were concerned at the number of "broken families" and homes with "too much drugs/alcohol/family violence". They were distressed that too many children were leaving home to meet physical safety needs and felt there should be more safe houses for children in the community. Neighbourhood fighting was also considered a serious problem. Many of the Kununurra participants had experienced sleepless nights due to fighting and drinking nearby. In Wadeye, at the time of the June workshop, children had been hospitalised following community violence. People called for the fighting to end and for the "community to be free of alcohol, and respect to be at the heart of it". --- Education and employment Education was seen by participants as essential. They noted that "It's hard for young people to get good jobs if they don't have education". People reported that they were worried that young people weren't getting enough education. Some commented that only two houses with kids in the community go to school. When they were younger, everyone went to school. If kids miss out on too much education it's hard for them to go back to school. Distance education for remote primary and secondary students and boarding school in Perth had become options for some young people. But many felt that education should involve access to mainstream education as well as learning cultural knowledge. Participants also emphasised the need for life-long learning, including through training in areas such as land management, managing money, and gaining a driver's license. Participants discussed the need for more employment and had a range of employment ideas including aged care as "there are older people in the community that need looking after". Other suggestions included collecting bottles and cans for recycling; this was happening in Wadeye and could also happen in Kununurra. It was anticipated that the prawn farm project would provide employment opportunities. --- NEXT STEPS -MEASURING CHANGE Once the domains of change were agreed with NTHs, the next step was to develop the tool through which to monitor change in those domains over time. In line with experience in Western Australia , the original plan had been to develop unique measures based on TO feedback. However, a broader scoping of the experience in Australia identified an existing Aboriginal well-being survey tool that appeared to capture these themes as well as others of potential relevance. The Mayi Kuwayu survey was developed at the Australian National University by Aboriginal researchers in consultation with Aboriginal groups and organisations across the country as part of a major national study of Aboriginal and Torres Strait Islander well-being and the value of culture for people. The survey includes the domains of identity, language, culture and community; health; experiences; and family support . Table 1 provides examples of domains and themes addressed within the MK survey that aligned with the areas identified by NTHs. At the September 2019 workshop in Wadeye, a selection of questions from the MK survey was tested with NTHs to assess their relevance and acceptability. Questions related to leadership, connection to culture, family and community relationships, health, education, employment and financial management were written on flipchart paper and NTHs were asked to work in small groups to rate how important these were and how well they aligned with their own ideas about wellbeing, and to provide explanations for their rating. The NTHs engaged deeply in this process. They found the MK survey questions to be relevant, addressing the issues of most concern to them, and an appropriate tool for measuring change in their communities. They expressed interest in learning more about the broader MK study. With NTH agreement, the NLC invited a team from the Australian National University to support implementation of the survey with NTHs in Wadeye and Kununurra. This included training and support for a small group of community researchers to administer the survey, analyse the data, and report the findings. The NTH group identified a senior woman and two women from the next generation with the skills and capacity to take on the community researcher role. The work commenced in 2020 and to date three community researchers and an NLC staff member have been trained to support local people to complete the full survey. The NLC officer took on a coordinating role and managed logistics, and community researchers led the survey processes including obtaining consent and maintaining confidentially and cultural safety. 28 surveys have been returned and initial analysis has been completed. Initial review by NTHs indicates that they have found the results relevant to their situation and useful as a basis for further discussion about their development aspirations and intentions. A full process for communicating all the results including comparison across several measures between this group and Aboriginal people living elsewhere in Australia, is being implemented, at the direction of NTHs. This process, expected to take some months and to be accompanied by additional development and facilitation activities, will be the subject of future reports. Checking up to keep on track has not been easy to develop in these two remote Aboriginal communities. The logistics involved in both establishing the approach and then administering the MK survey have been extensive and time consuming. There have been some particular challenges in the early phase of administering the MK survey in Wadeye and Kununurra, including the impact of the COVID-19 pandemic on travel, competing organisational and community priorities and demands, and the length of time and level of support required for people to complete the survey. Some of these challenges were mitigated through the engagement of the community researchers, who worked with NTHs and other participants, finding the 'right' times to invite them to complete the survey, supporting them with transport to a quiet location where they could focus on the task and sitting beside them to assist with explaining survey questions and requirements. Community researchers played an important role as interlocutors for the MK dialogue and ensuring the survey could be completed in a culturally safe way. A side product of the whole process has been the upskilling of these local researchers. The capacity of NLC and the local researchers to regularly repeat the survey and build the knowledge base of NTHs, supporting them to interpret the data and its value in assessing shorter term activities, are all still to be tested. --- DISCUSSION Aboriginal-led approaches to monitoring and evaluation are vital for both quality improvement of programs and for providing Aboriginal people some control over those programs. This paper reports the process of identifying a well-being monitoring approach for a community development program with Aboriginal NTHs in Northern Australia. In this innovative approach, an empowerment based Aboriginal Family Well-being framework enabled deep reflection and the articulation of areas of value to the local groups, namely: qualities for leadership; connection to culture; and community level indicators of safety, education, and training; and employment. These domains aligned with and clarified earlier work undertaken with the NTHs to identify their long-term vision. They also aligned with an existing culturally sensitive well-being survey tool created by and for Aboriginal people . Our subsequent trial of parts of the survey within the workshops highlighted its potential to be used for monitoring Aboriginal well-being, as defined by NTHs, thereby mitigating the need to create a new measurement tool and 'reinvent the wheel'. Despite logistical and some other difficulties, reports to date indicate that the NTHs have appreciated the opportunity to reflect on the issues raised by the MK survey and to be involved in the study. The support offered by community researchers in terms of organising a quiet place with no distractions as NTHs completed the survey, being able to work on the survey at a time which best suited their other commitments and having the help with understanding offered by the community researchers all clearly improved the process. Beyond this the NTHs identified that the survey was relevant. They saw in the questions the areas or domains they had identified and discussed. They were able to connect the survey to their original aspirations and ideas for change. They considered that information about these areas was relevant to the decisions they will make for the well-being of themselves and others. The next step in the process will be for the ANU MK research team to complete the analysis of the MK surveys and for NLC to work with the NTHs to explore the significance of these results. Being part of a national study of Aboriginal and Torres Strait Islander Wellbeing will start to give the NTHs some information about their well-being compared to others and a base measure from which to assess if things are improving or not. Longer term, as the survey is repeated, those NTHs will be able to assess how well they are progressing to increased well-being in their location, as they define it. The intention is that they will be in a more informed position to judge the value of the community development projects. The attempts to provide Aboriginal people with a broader and more long-term perspective from which to judge the value of short-term projects is a different approach to traditional program assessment . It attempts to provide a group of NTHs with a more relevant frame to assess all the activity in their place, one that includes the areas or domains they have identified as significant. This approach has the potential to widen the knowledge base from which Aboriginal people can make judgements about the worth of any activity or project, both those supported by NLC and others.

This paper reports the process of identifying a well-being monitoring and evaluation approach for a community development program with Aboriginal Native Title Holders in Northern Australia. The process involved the use of an empowerment based Aboriginal Family Well-being framework to enable Native Title Holders to articulate domains of value to their local community. These domains aligned with an existing culturally sensitive Aboriginal well-being survey tool which the Native Title Holders saw as relevant for their use. The attempts to provide Aboriginal people with a broader and more long-term perspective from which to judge the value of short-term projects is a different approach to traditional program assessment (monitoring and evaluation). It aims to provide Aboriginal people with a more relevant frame from which they can make judgements about the worth of any program or project in their location, supporting local control and decision making. Potentially it provides Aboriginal people with the information from which to advocate for other supports and to assess the value of Government and other projects.

the south or from the north to the north . At present, most international migrants are of working-age and live in Europe, Asia and North America . Apart from international migrants, an astonishing figure of 740 million people is estimated to have migrated internally within their origin country. 1 Migration is as old as humankind. People have always moved in search of better living conditions for themselves and for their loved ones or escaping dramatic situations in their homeland. These two major drivers were the fundamentals of the 'push and pull' theory that was first proposed by Lee in 1966, 3 encompassing economic, environmental, social and political factors pushing out from the individual homeland and attracting him/her towards the destination country. Lee's theory has the merit of being one of the first trying to identify in a modern and scientific way the drivers of such a complex phenomenon after Ravenstein first addressed them in Scotland in 1885. 4 The main elements of the 'push and pull' theory will also be considered in this article for didactic purposes, but the Author recognizes that in the current global world reality is certainly much more complex and faceted, involving both local national realities and macro-level causes as well as mesolevel and micro-level causes related to the link of the individual to his/her ethnic or religious group and the personal characteristic of the individuals respectively. 5 Recently, the 'pull-push plus' theory has also been proposed, which considers predisposing, proximate, precipitating and mediating drivers of migration. 6 Regardless of the theoretical framework adopted, the topic addressed by this article is difficult because sound scientific data are scarce, existing literature is mainly qualitative and often presented as grey literature. In addition, geographical and cultural elements may influence the weight of the single determinant in different continents and in different periods. Finally, although the various drivers will be presented separately, we recognize that they are part of a unique complex scenario where they strongly interact. --- Definition of migrants According to the International Organization for Migration , a migrant is 'any person who is moving or has moved across an international border or within a State away from his/ her habitual place of residence, regardless of the person's legal status; whether the movement is voluntary or involuntary; what the causes for the movement are; or what the length of the stay is', a broad definition indeed. Under such definition, and strictly limiting our analysis to south-to-north migrants, two major broad categories may be identified: Labour migrants and Forced migrants ; whose reasons to migrate may differ, even if difference between the two categories are probably smaller that estimated once and the same migrating individual may fall in one or the other category at the same time. 5 In this respect, it is useful to report below the synthetic definitions of asylum seekers and refugees from IOM. 7 --- Asylum seeker A person who seeks safety from persecution or serious harm in a country other than his or her own and awaits a decision on the application for refugee status under relevant international and national instruments. In case of a negative decision, the person must leave the country and may be expelled, unless permission to stay is provided on humanitarian grounds. --- Refugee A person who, 'owing to a well-founded fear of persecution for reasons of race, religion, nationality, membership of a particular social group or political opinions, is outside the country of his nationality and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country .' --- Drivers of migration The factors acting together and determining the final decision of an individual to migrate may be subdivided in macro-elements , meso-elements and micro-element . Those that have been more extensively studied will be discussed in this article. --- Inadequate human and economic development Human development is enormously unbalanced in the various regions of the planet and the gap is increasingly wide. The economic and political reasons underlying this sad situation are beyond the scope of this article and will not be addressed here. The Human Development Index is a composite index combining the performances of the different countries on health , education and economics proposed by the United Nations Development Program . The 2016 HDI top ranking includes 15 western countries and 5 Asian countries among the first 20 ranked nations. 8 At the opposite extremity of the list, 19 out of the last 20 nations with the lowest HDI indexes are from Africa, a striking difference. However, during the first decade of the new millennium, many African countries experienced a remarkable economic growth, with gross domestic product increases exceeding 5% in average according to the International Monetary Fund. Unfortunately, the consequent relative wealth has not been equitably distributed in the population and the subsequent world economic crisis since 2011 has slowed down the economic performances of most African countries to a bare 2% yearly GDP increase. As a consequence, most jobs in developing countries are still in the informal sector, with little salary and social protection, thus nurturing the willing to find better job conditions elsewhere. Low performances in the health, education and economic sectors are a reflex of the vulnerability of the health, education and productive systems which is caused by the lack of economic and human resources. With particular regard to the health sector, such situations that provide little professional and economic motivation pave the way for qualified health professionals to leave their origin countries, a phenomenon known as 'brain drain' and creating a vicious circle. Poor health services, little educated and qualified work force and poverty are a fertile background promoting migration of individuals in search of better life. New communication technologies, largely available in urban settings even in developing countries, allows people to compare the western lifestyle with the local situations where the luxurious houses and cars of expatriates often contrast with the poor living conditions of the local populations. The gradient of prosperity. Migration and development are strictly linked and influence each other. Paradoxically enough, in fact, migration may be driven by both a lack of development and by an increasing socioeconomic development in a specific country, at least in the initial phase. 9 --- Demographic increase, urbanization The world's living population has increased in an unprecedented way during the last two centuries, from 1 billion estimated to live in the year 1800 to the more than 6 billion living at the beginning of the second millennium, to the roughly 11 billion that will probably inhabit the earth in 2100. 10 The bulk of this massive increase is taking place in Asia and Africa, where high fertility rates, driven by infant mortality, and poor birth control programmes result in high annual population increase rates. On the contrary, the fertility rate in western industrialized countries is shrinking. According to the World Bank, the average fertility rates in high income countries was 1.7 children per woman in 2015, while it was 4.8 per woman in low-income countries. 11 As a global result, the population of western industrialized countries is reducing in size and getting progressively old , while the young working-age population of the developing countries is rapidly increasing. The African continent offers a striking example. From 493 million in 1990, the African population grew to 1 billion in 2015 and it is expected to rise to 2.2 billion in 2050 and to 4 billion in 2100! 12 With particular regard to the African continent, the increasingly young population will probably exceed by far the otherwise improving-but not equitably distributed-economy, giving origin to the so-called 'jobless generation' phenomenon. This means that the increasing global wealth is not mirrored by a proportional number of jobs to satisfy the increasing expectations of the growing skilled young generation, at least in the short-medium term. 13 As a matter of fact, the flow of migration in relation to demographic increase could also be regarded in the opposite way, raising the question 'why do so few people migrate?' 14 In fact, even if the stereotype of migration proposes a model of 'mass' invasion of rich countries by migrants from low-income countries in terms of absolute numbers, the proportion of migrating people is quite stable . --- Climate changes It is now almost universally accepted that the climate is becoming warmer and warmer at an increasing speed, causing health inequalities across the world 15 apart from other unwanted effects. It is also accepted that the driving causes of such climate changes started with the industrial revolution, are mainly anthropogenic in nature and are largely due to the emission of greenhouse gases by industrial activities from carbon-based energy. It has been estimated that 97% of such emissions occur in industrialized rich countries, leaving a mere 3% emission coming out from low-income countries. 16 The impact of climate changes is astonishingly severe in the south of the world, where 150000 are estimated to have died in 2000 from the consequences of the planet warming. 17 Drought, flooding, increases in arthropod borne infections due to vector spreading in regions where the contrast measures are difficult to implement due to scarcity of means also indirectly impact on morbidity and economic agricultural revenues. The case of Lake Chad is extreme but enlightening. From the nearly 25000 square kilometres Lake Chad had in 1963, its water now covers a bare one-twentieth of its original extension, with severe impact on the fertility of the surrounding land. This shortage of water, food and agricultural resources forces people and livestock to move in search of a less hostile environment. 1 Examples of land degradation induced by climate changes are multiple and represent a driving force for people to migrate by producing food insecurity and risk of health-related crisis. 18 According to the IOM, environmental migrants are those 'persons or groups of persons who, for reason of sudden or progressive changes in the environment that adversely affect their lives or living conditions, are obliged to leave their habitual homes, or choose to do so, either temporarily or permanently, and who move either within their country or abroad'. 19 It has been suggested that the environment may impact on migration flows by directly affecting the hazardousness of place but also indirectly changing the economic, political, social and demographic context with very complex interrelationships. 20 The 'climatic migrants', as they are sometime called, might possibly reach the astonishing figure of 200 million by the year 2050, according to the IOM. 21 However, forecasts are difficult to make because sound scientific data on this topic are extremely scarce and do not permit reliable estimates. 22 The assessment of the real impact of worsening environmental conditions, albeit logical, would greatly benefit from sound research studies. --- Wars and dictatorship Even now, at the beginning of the third millennium, many areas of the world-in virtually all continents-host bloody conflicts and social instability where armed parties fight or where rude dictatorships are ruling and denying social rights. Some are well-known to the public , while others are not as is the case of the Horn of Africa and some areas of West Africa and the Sahelian region or in Central and Southern America. 1 People may be denied basic human rights and the access to education and to a dignified life may be prevented, especially for females. Fundamentalism is such countries may easily grow, as it is the case with the deadly activities of Boko Haram in Northern Nigeria, that it is estimated to have caused the internal displacement of nearly 2 million people. 23 It is to be noted that the majority of displaced people in warring nations are relocated within national borders, thus officially they are not considered international migrants, but rather internal refugees. --- Land grabbing Land grabbing is a phenomenon that has become increasingly important since the beginning of the new millennium. The term 'land grabbing' refers to the intensive exploitation of vast areas of land in rural areas of low-income countries by private international enterprises or even by foreign governments in order to implement large-scale intensive cultivations or to exploit minerals, forestry or the touristic industry. This happens to the detriment of the poor local population, which is poorly compensated and virtually obliged to leave the rural areas to reach the degraded urban peripheries within their own countries, where they often live a difficult life in a different setting from the one they and their families have experienced for centuries. Psychological and physical impairment is frequent in such communities and international migration may then occur. Apart from this direct impact, the economic benefit of small-scale agricultural industry is of advantage of the local communities, while the intensive exploitation of lands as a consequence of land grabbing is mainly to the benefit of the private enterprise stock owners and the international market, 24 leading to the progressive impoverishment of the increasingly resource-poor country. Together with environmental damages due to climate changes, the loss of small-scale land property and its turning into intensive exploitation causes a progressive land degradation, which leads to a progressive abandonment of native lands by a mass of people. 25 --- Religion This issue will only be briefly alluded to, as it is too wide and complex to be adequately addressed in such context. The history of humankind offers many examples of mass population movements caused by religion persecution or following the dream of a land where individual faith could be freely preached. However, these movements have often been the consequence of a political will as it has been the case of the conflictive Muslim, Hindu and Sikh movement across the newly created border between India and East Pakistan in 1947. Similarly, Jews flowed to Palestine after the Second World War, also attracted by the law of return, favouring migration of Jewish people to the new state of Israel. In many other instances, religion has been the pretext for ethnic persecution and expulsion, as is possibly the case for the Rohingya Muslim population from Myanmar or the mass movements caused by armed fundamentalists groups such as Daesh or Boko Haram in the Middle East and sub-Saharan West Africa, respectively. --- Sexual identity A number of countries have a quite restrictive policy on sexual identity and LTGB people face psychological and even physical violence, forcing them to hide their sexual identity. The impact of such policies on international migration has recently been the subject of some investigation that is in its infancy. No doubt, however, that an impact exists, especially from countries where 'machismo' is considered a value. 26,27 A comprehensive overview of the issues related to the protection of social rights in those people forced to migrate due to their sexual orientation may be found in the 2013 thematic issue of Forced Migration Review. 28 --- Education A final note has to be dedicated to the education level of migrants. International migrants are often regarded as illiterate and poor people escaping poverty from remote rural areas. This stereotype is far from being true in most instances for both economic and forced migrants. Migrants in search of a better future usually have a more pronounced initiative, attitude and boldness than the average person, with some skills and financial resources needed to plan and fund a long-distance journey as it is the case for international migration. 29 In most instances, they are more educated than their peers left behind in their origin country. 30 Sometimes they are even more educated than their peers in the destination country. 31 In addition, individuals from families or communities that already positively experienced migration in previous years are more inclined to migrate as their travel abroad is regarded as of possible benefit to the origin society. 5 For such individuals, the existence of ethnic or family links in the destination country is a further driver of migration. The relationship between education and migration are twofold. From one side, the migration of educated people from lowmiddle income countries to OECD countries constitute a net loss of human qualified resources for the origin countries and a gain for the host country. A phenomenon known as 'brain drain'. From the other side, the financial and ideational remittances from destination countries may also have an impact on the education of non-migration children and adolescents in their origin countries. 30 --- Personal willingness to migrate All the above drivers of migration act, with different strength in different places, to build the general frame at the macro-level of each specific geographical, economic and political situation. However, the meso-or even micro-levels are also important in driving the final choice of the individual to migrate. The influence of the ethnic group, the family support-both economic and societal-is of the upmost importance for a specific individual to make the final choice to migrate or to stay. Educational level and access to financial means permitting to afford the migration travel have already been discussed above, but other factors such as ethnic and social customs are also important. The aspiration and desire to migrate is a crucial key factor that interacts with other external drivers of migration to build the final decision to actually migrate. 32 Health challenges in the destination country Regardless of the mix of drivers leading to migration in any individual person, migrants usually undergo a difficult integration process in the hosting community. Conversely, the receiving country could also be obliged to adapt its social and health systems to face the needs of the hosted population. In many instances, this process is not without conflict for the cultural and economic adaptations that it implies. From the health point of view, although generalization is inappropriate due to the heterogeneity of provenance and epidemiology of diseases in the origin countries, newly arrived migrants are usually healthy but more affected by latent infections than the host populations, 33 requiring screening policies and links to care. Crowded and inadequate living conditions in hosting camps may also lead to infectious diseases outbreaks, as recently reported in France. 34 However, despite the reported higher prevalence of selected infections in migrants, including potentially diffusive respiratory tract infections, the risk of significant spread in the receiving populations has been reported to be negligible, if any. 35 Once resettled in the host country, foreign-borne individuals may face infectious exposure when travelling back-often accompanied by children born in the host country-to their countries of origin. They are then referred as VFRs , and represent a significant proportion of imported diseases in western countries, as in is the case for imported malaria. 36 Pre-travel advice in such VFR populations poses significant challenges to optimally address adequate preventive measures. 37 However, even the non-communicable diseases burden is increasing among migrants, as a result of changing alimentary habits in developing countries and to the progressive acquisition of western lifestyles after a few years in the receiving country. 38 Finally, the cultural interaction between the migrant patient and the care provider is often not without conflicts. The emphasis on the possible exotic nature of otherwise ubiquitous illnesses or, on the contrary, the underestimation of culturally bound complaints are often aggravated by linguistic barriers leading to potential medical errors. The knowledge of culturally sensitive medical issues, such as genital mutilations, is generally poor in western physicians, requiring specific training and research. 39 --- Conclusions In conclusion, the migration flow is now a structural phenomenon that is likely to continue in the next decades. While many migrants from low-income countries aim to reach more affluent areas of the world, it is to be appreciated that a similar, or even bigger, mass of people migrates to neighbouring low-income countries in the same geographical area. Migration is always the result of a complex combination of macro-, meso-and micro-factors, the former acting at the society level and the latter acting at the family or even individual level. The prevalence of a factor over the other is unpredictable. Among the 'macro-factors', the inadequate human and economic development of the origin country, demographic increase and urbanization, wars and dictatorships, social factors and environmental changes are the major contributors to migration. These are the main drivers of forced migration, both international or internal. Among the 'meso-factors', linking the individual to his/her ethnic group or religious community, land grabbing, communication technology and diasporic links play an important role. The role of communication technologies and social media to attract people out of their origin countries is indisputable today. Awareness of living conditions in the affluent world-albeit often grossly exaggerated-contributes to nurture the myth of western countries as Eldorado. The ease of communication with the diaspora and family members who migrated previously reinforces the desire of escaping from poverty to a challenging new life abroad. However, 'micro-factors' such as education, religion, marital status and personal attitude to migration also have a key role to make the final decision to migrate that is an individual's choice. In any case, the stereotype of the illiterate poor migrant coming from the most remote rural areas and reaching the borders of affluent countries does not stand. The poorest people simply do not have the means to escape war and poverty and remain trapped in his/her country or in the neighbouring one. Some degree of entrepreneurship, educational level, social and financial support is usually requested for international south-north economic migration and personal characteristics and choices also play a role. This phenomenon has a positive aspect, as the possibility of success of migrants increases as do remittances, but also a negative one, as the most active part of the origin country may be drained preventing local development. Usually, even if generalization is inappropriate, newly arrived migrants are in good health, despite a higher prevalence of latent chronic infections . However, marginalization in the host country may lead to a deterioration of such health status, a phenomenon known as the 'exhaust migrant' effect. Host countries, which may have also an economic benefit from migration in the medium long-term, have to be prepared to receive migrants for the benefit of the migrants themselves and their native population. --- Conflict of Interest None declared.

More than 244 million international migrants were estimated to live in a foreign country in 2015, leaving apart the massive number of people that have been relocated in their own country. Furthermore, a substantial proportion of international migrants from southern countries do not reach western nations but resettle in neighbouring low-income countries in the same geographical area. Migration is a complex phenomenon, where 'macro'-, 'meso'and 'micro'-factors act together to inform the final individual decision to migrate, integrating the simpler previous push-pull theory. Among the 'macro-factors', the political, demographic, socio-economic and environmental situations are major contributors to migration. These are the main drivers of forced migration, either international or internal, and largely out of individuals' control. Among the 'meso-factors', communication technology, land grabbing and diasporic links play an important role. In particular, social media attract people out of their origin countries by raising awareness of living conditions in the affluent world, albeit often grossly exaggerated, with the diaspora link also acting as an attractor. However, 'micro-factors' such as education, religion, marital status and personal attitude to migration also have a key role in making the final decision to migrate an individual choice. The stereotype of the illiterate, poor and rural migrant reaching the borders of affluent countries has to be abandoned. The poorest people simply do not have the means to escape war and poverty and remain trapped in their country or in the neighbouring one. Once in the destination country, migrants have to undergo a difficult and often conflictive integration process in the hosting community. From the health standpoint, newly arrived migrants are mostly healthy (healthy migrant effect), but they may harbour latent infections that need appropriate screening policies. Cultural barriers may sometimes hamper the relation between the migrant patient and the health care provider. The acquisition of western lifestyles is leading to an increase of non-communicable chronic diseases that require attention. Destination countries have to reconsider the positive medium/long-term potential of migration and need to be prepared to receive migrants for the benefit of the migrants themselves and their native population.

Introduction Community policing is being accepted as the new face of increased security in much of the world, including Europe, the United States, Australia, Asia, South America, and Africa. In England, the police gained more power and moved closer to society after Sir Robert Peel introduced community policing as a tool for fighting crime . This reform in London's government started in the early 1990s, along with the move to become a police officer, thereby preventing crime . Community policing in the United States began in the 1970s, although most law enforcement agencies did not fully embrace the concept until 1980. An arms exchange program was instituted in Mendoza, a province in Argentina, which led to intense participation. leads the Community's Commitment to Security Policy . The use of information systems has been emphasized to identify and analyze the problems faced by the community . The police need to share critical information with the public on how to handle different criminal activities. In most cases, the public lacks knowledge and information on actions to take when encountering security situations. Hence, the police need to furnish people with the necessary information. Further, a suggestion is made that the required information can be gathered from various sources such as appraisals that showcase community police performance; evaluations of the overall police performance from standard indicators. He emphasizes that qualitative information should be used rather than old methods to measure success. The proposed study seeks to examine whether law enforcers in Rwanda have the necessary facilities to enhance the collection and sharing of information about community policing . --- Problem Statement The Rwandan government has shown its commitment to improving security by establishing a community police force in 2007. However, cases of uncertainty are still widespread. A report by the Rwandan National Institute of Statistics recorded 34,179 crimes in 2017, 43,279 crimes in 2018, 71,360 crimes in 2019, and 86,713 crimes and child abuse in 2020. Crime has been steadily increasing since 2017 and in 2020 crime has doubled compared to 2018. From the statistics above, the provincial crime statistics for 2019 show that the city of Kigali recorded the highest crime rate with 17,092 crimes. In addition, crime statistics recorded for each district in 2015, 2016, and 2017 show that Gasabo District has the highest crime rate compared to other districts with 1,607 crime cases in 2015, 1,805 cases in 2016, and 2,884 cases in 2017 . In addition, the NISR report shows that the number of crimes increased to 71,092 in 2019 and 86,731 in 2020. The above statistics confirm that there is a serious security problem in Rwanda, especially in the Gasabo district located in the city of Kigali. This situation, if left unchecked, could lead to high levels of crime and insecurity in the country. Despite the introduction of community police in Rwanda, there is still a high prevalence of crime. There is little research on the role of community policing in enhancing security. Based on this premise, this study sought to fill the knowledge gap by assessing the impact of community police information sharing on improving security in the Gasabo District, Rwanda. --- Literature Review 2.1 Theoretical Review Shaw and McKay initiated the social disorganization theory. It is founded on the perception that communities that are not organized face breaks in their informal social controls that translate to crime occurrence. It becomes difficult to handle crime incidence in a disorganized location. Shaw and McKay used spatial maps to inspect the residential locations of juveniles and realized that the rates of crimes were not appropriately distributed across the space and time in Chicago city. The police service is supposed to curb the social disorders that arise in the community. Therefore, their take as far as social disorganization is concerned is to take appropriate measures to increase the volume of the communities to exert informal social control. The primary goal of this theory is to develop formal social control techniques. It, therefore, emphasizes the essence of organizing communities. Organization of communities can take different angles. For example, engaging local business holders to help them identify and solve their problems, visiting residents to offer advice on matters of security, and helping in the facilitation of community meetings. However, critics argue that the scope of this theory is narrow and that it's only applicable in the context of community policing. Further, Shaw and McKay did not differentiate between the presumed outcome of social disorganization and the disorganization itself, and there has been much confusion regarding the conceptualization of social disorganization . Nonetheless, the theory is suitable for this study since the main focus is community policing. The social disorganization theory is important in the examination because it stresses the essence of community organization and its primary goal focusing on the development of social control techniques. In line with the theory, one of the ways of achieving community organization is through the promotion of partnerships among key players such as police and community members . When there is a good working relationship between these parties then it becomes easier to organize the community and this translates into enhanced security. Another way of organizing community as suggested by the theory is through citizen sensitization. Creating awareness among community members on matters to do with security and community policing is critical in ensuring that communities come together in the fight against crime . Further, information sharing is a key factor in achieving cohesion among stakeholders within a community. It also facilitates the proper organization of the community in an effect to fight insecurity. Therefore, in this research, the theory of social disorganization is essential as it provides an argument that supports the role of information sharing in enhancing security. This is achievable when communities are properly organized as pointed out by the social disorganization theory. --- Empirical Review To succeed in community policing, an implementation must be on point, hence the determinants that impact the implementation of community policing and the kind of impact it has on police work, communities, and crime rates are important. Muteti, Mbirithi, and Kiruthu in their study identified information sharing as a key determinant of effective community policing for enhanced security. In particular, the public has a responsibility of sharing vital information with the authorities. The initiative by the public to share timely information will enable the police to prevent potential crimes. This will ultimately enhance security. The proposed study also seeks to examine the role of information sharing in enhancing security in Rwanda. Headayetullah, Pradhan, Biswas, and Puthal attempted to come up with a secure digital system for information sharing which would improve homeland security. They noted that it was important to enable the sharing of secure information among the citizens or other governments. The study emphasized the significance of information sharing in enhancing security. However, the research was centered on the United States context. The proposed study seeks to examine the effect of information sharing on security enhancement in Gasabo District, Rwanda. It is the plea of law enforcement agencies for the IT to back their operations, from determining identification and past histories of people clogged in the field, to working hand in hand with detectives as they conduct their investigations, to passing on helpful information to commanders . For effective crime prevention, readiness, response, and recovery exertions, there must be timely, accurate, and functioning information about who the culprits are, how and where they operate, the targets of the culprits, and also the method they intend to use to attack. The Department of Homeland Security is an agency that is purposely designed to link up 5 U.S territories, 50 states, and major urban areas. This infrastructure is developed to utilize information and resources available at the state, federal and grassroots levels, which enhance real-time partnership and information exchange for awareness and quick response. An initiative by intelligence agencies works out well: whereby various agencies agree to assemble and share information, analyze the possible threats, plan for the response measures, and plan on the communication methods to be applied at the time of the attack. A director of Research for the National Memorial Institute for the Prevention of Terrorism said that the direction of readiness can be given by people who look at the possible threats . The community has a crucial role to play when it comes to community policing. Whereby, they must be willing to volunteer any information on suspicious people or activities to the police. They must be willing to work closely with the police in the set forums of community policing. These include offering support to the police and exhorting communication between neighbors. More so, the members of the community should support the awareness the police make by extending it to their fellow neighbors. --- Conceptual Framework This conceptual framework presents the study variables and their components that guide the investigation leading to study findings. Figure 1 shows that the independent variable influences the dependent variable . --- Methodology The study adopted a mixed methodology approach and a concurrent triangulation design. The study targeted approximately 139,358 household heads of Gasabo District, 73 Community Policing Committee chairpersons, 15 Community Liaison Officers, and 260 Police Officers. The study sampled 576 household heads for quantitative data whereas the CPC chairpersons, Community Liaison Officers, Police Officers, and Opinion leaders were used for qualitative data. A multistage sampling technique was used to select the participants. Questionnaires, interview guides, and discussion guides were used to collect data. The reliability of the questionnaire was tested by Cronbach Alpha. The coefficient value used was 0.7. To ensure the validity of the questionnaire, it was reviewed by the supervisors. Trustworthiness of the interview and discussion guides was ensured using both dependability and credibility. For dependability, the researcher ensured that every step of the process was clear, while credibility was ensured through the use of appropriate research methods. SPSS software version 25.0 was used to analyze the data. Quantitative data were analyzed using descriptive statistics and inferential statistics , which was used to determine the relationship between the factors of the research. Qualitative data from the interview guides were analyzed thematically and presented in narratives. --- Results and Discussion --- Reliability Testing The researcher used Cronbach's Alpha to check whether the instrument was reliable. Cronbach's Alpha will use 0.7 as the recommended value as the cut-off of reliability for this study. --- Table 1: Reliability test The findings in Table 1 indicate that the security enhancement variable had a Cronbach alpha value of 0.817, and information sharing had 0.78. This denoted that all the variables had values greater than 0.7 implying the reliability of the data collected. According to Sheth and Naik , items with alpha values greater than 0.7 are considered reliable and are adopted for the main study. Therefore, the items measuring the study variables were reliable and hence were adopted in the subsequent analysis. --- Security Enhancement Indicators Findings Descriptive Statistics on Security Enhancement The dependent variable in this study was security enhancement. Table 1 shows the descriptive statistics on security enhancement. The results are presented in frequencies, percentages, means, and standard deviations. The following scale was used: strongly disagree , disagree , neutral , agree , and strongly agree . Vol: 2, Issue: 4 July-August/2023 DOI: http://dx.doi.org/10.47742/jhssr.v2n4p1 https://jhssrnet.com/index.php/jhssr --- Table 2: Descriptive Statistics on security enhancement As indicated in Table 2, most of the respondents agreed that there is increased crime prevention due to community policing. The respondents also agreed that there is improved social cohesion due to community policing , there is increased community safety due to community policing , and there is a reduced number of arrests made due to community policing . Further, the majority of the respondents agreed that there is a reduced number of crime cases reported due to community policing, there is a reduced number of incidents reported due to community policing , and there is a reduction in restricted movement due to community policing . The findings imply that most of the respondents had positive opinions towards security enhancement using community policing. Therefore, security enhancement could be attributed to community policing components. According to Javed et al. , an individual feels secure if he/she has a job and health security and lives in an environment free from crime. The respondents were requested to give their opinion regarding how the security could be enhanced and the opinions are presented in Figure 2. This was followed by those in the opinion of increased training at all levels/sectors as indicated in Figure 2. --- Thematic Analysis on Security Enhancement The respondents were asked to state the role of community policing in enhancing security. The respondents noted the need to put suggestion boxes in the villages, for police and citizens to carry out joint patrols, regular training to the population at all levels for both adults and youth, and establish police posts at every cell to provide the population with fast services. Rexer and Patil stated that community policing is one of the approaches by which countries can enhance their security. It makes everyone develop a sense of responsibility in promoting peace and unity. The respondents also noted the importance of installing more security cameras, police deployments should come down to the cell level for quick intervention, an increase of police stations, and police should train the local population in villages and cells about community policing periodically. It was recommended that police should reduce brutality to enhance security. One respondent, R3, was quoted saying… "Crimes have reduced however; Police takes time to intervene in case of incidents thus, a need for police to increase response time where there are incidents". --- Responses from Interview guide by CPC and CLOs The participants were asked to explain how community policing had influenced the various security enhancement aspects in Gasabo District. The participants noted that crimes have been reduced, security information was shared timely, and use of police free call lines. Further, citizens are now living in peace and have hope for the future. Domestic violence reduced. In addition, security is guaranteed, life expectancy is increased, there are local patrols in villages and neighbors would watch. On crime prevention, participant P1 stated that … "Police citizen collaboration has helped in information sharing about crimes before they happen to police which helps to prevent crimes". On social cohesion, participant P3 noted that… "Police help in resolving crime-related problems of the people living in Rwanda and this increases the trust between police and population thus, promoting harmony with one another in our community". Participant P4, reiterated that… "Due to different community policing programs in Gasabo district security has been improved and people are living in harmony with one another, there is no mistrust among the community members". On community safety, Participant P1 stated that… "The community safety is generally good no serious crimes have been registered for the last 06 months in our sector Kimihurura, people living in Rwanda work hand in hand with the police to resolve any security matter that may arise". Participants P3, observed that… "In our sector, Remera security has improved because through police sensitization we now understand how we can take part in the provision of security in our community". Participant P5, reiterated that… "The community safety has increased in Gasabo district this is because people now are partners in security matters when any incident happens members of the community report it to police immediately and work together to resolve it". Participant P7, stated that… "Where there are police, security is granted in case of any issue Police can easily intervene, in Gasabo district we trust Rwanda National Police and we are ensured of security". --- Responses from focus group discussions by community leaders The church leaders were required to explain how community policing had influenced the following security enhancement aspects in the Gasabo district. On crime prevention, one of the discussants, D18 stated that… "Generally, crimes have been prevented and thus really reduced. For example, the crime of using forced labor within homes, and child labor has been reduced to some extent just because of information sharing because now before you hire a worker you first have to ask for a national identity card to make sure that you are preventing yourself to commit the above crime". On social cohesion, the discussant D18 observed that … "Initially when all people have peace with belief that they have to protect one another implies such social cohesion. Because regardless of your social category whether poor or rich you just believe that even your fellow citizen is a human being hence promoting social cohesion. Also, the other initiative of the 'Akagoroba k'ababyeyi' evening parent meeting has indeed brought remarkable change concerning social cohesion. Simply because it is from this evening meetings where all social values are learned, and this social dialogue builds the closest relationship hence promoting social cohesion". On community safety, discussant D19 cited that … "Concerning community safety, right from the beginning we talked about self-initiative of neighborhood watch. Everyone is now aware that he/she is responsible for his/her security. The great work of civilian local patrols is another initiative that promoted community safety because they are everywhere compared to police who cannot manage to be in every house. Lastly, the idea of making police call number to be known everywhere has also promoted community safety". --- Mixing and Interpreting of Quantitative and Qualitative Data Data on Security enhancement was analyzed using descriptive and thematic. From the descriptive point of view, the majority of the respondents reported that there was increased crime prevention due to community policing, there was improved social cohesion due to community policing, there was increased community safety due to community policing, there was reduced number of arrests made due to community policing, and there was reduced number of crime cases reported due to community policing. The thematic analysis had similar results where participants reported that there was a general improvement in security. --- Influence of Information Sharing on security enhancement The study sought to evaluate the influence of information sharing on security enhancement in Gasabo District, Rwanda. The section presents descriptive statistics, thematic analysis, and regression analysis results. DOI: http://dx.doi.org/10.47742/jhssr.v2n4p1 https://jhssrnet.com/index.php/jhssr --- Descriptive analysis for information sharing Table 3 shows the descriptive statistics on information sharing. The results are presented in frequencies, percentages, means, and standard deviations. The following scale was used: strongly disagree , disagree , neutral , agree , and strongly agree . --- Table 3: Descriptive statistics on information sharing As indicated in Table 3 about the distribution of community policing of information sharing on enhancing security, most of the respondents agreed that information on community policing is shared through social media , information on community policing is shared through music , and information on community policing is shared through word of mouth . Further, the majority of the respondents agreed that information on community policing is shared through acting , and that information on community policing is shared through training . The findings imply that information sharing on community policing is done using various channels. Most of the respondents had positive opinions towards information sharing. Therefore, information sharing is expected to positively influence security enhancement. According to Braga and Tucker , the use of information systems has been emphasized to identify and analyze the problems faced by the community. The respondents were further requested to give their opinion about the role of information sharing to enhance security and the opinions are presented in Figure 3. --- Figure 3: Respondents' opinion on the role of information sharing in enhancing security According to Figure 2, the common strategies of information sharing to enhance security mentioned by the respondents were timely information sharing , use of technology , training community members, and effective mechanisms of communication between police and citizens . --- Thematic Analysis on Information Sharing and Security Enhancement The respondents were asked to explain ways in which community policing information sharing can help enhance security. The respondents noted the importance of timely information sharing to prevent the occurrence of crimes, increase meetings with the community and convince them to give information about crime on time, have suggestion boxes in all villages, and social networks to be set up for each village to share information with police. According to Braga and Tucker , the use of information systems has been emphasized to identify and analyze the problems faced by the community. The respondents also observed the need to train community members on how to use the variable means of technology. One respondent, R7 stated that … "Toll-free lines at the cell level are needed and it should be communicated to everyone in the cell to be used in case of any security issue". Another respondent, R5 observed that… "Information sharing is not properly done because not everyone has means of communication thus a need to provide means of communication" Further, a respondent, R8 stated … "Kindly Police make communication easy by direct reply to the message received by Police related to security." The respondents further noted the need to use more radio and TV stations in information sharing, for police to work with telephone companies to share information with the local population about community policing to those with telephones and increase radio programs on community policing the ones we have are not enough. --- Responses from Interview guide by CPC and CLOs The participants noted that information sharing as a component of community policing is essential for security enhancement. They reported that police interventions were done timely. Participant P1, noted that…. "Timely reporting of crimes about to be committed that were reported to police has helped in arresting offenders, for example, some prostitutes locked up their children in Remera Sector and went for prostitution and when their neighbors heard children crying, they called Police for intervention". This has helped in protecting children rights". Participant P5 stated that… "crimes are reducing in our sector kimihurura this is because of the timely information shared with police". When asked what should be done regarding information sharing to achieve security enhancement in Gasabo District, the participants highlighted the following key themes; to provide communication equipment like telephones for easy communication; to provide professional services by police to the population; police should work together with local patrols to prevent crimes. Participant P4, stated that… "Information is shared timely and this has helped in crime prevention. Citizens reporting of crime has increased this has contributed to crime prevention and reporting of crime". He also recommended the following: Free police call lines to be used by the population just in case of any problem; regular meetings with citizens and use of police free lines; providing telephone to CPCs for them to be able to give information to the police; and citizens that have helped police in broking serious crimes should be rewarded to encourage other to do so. Participant P2, stated that… "Improvement on information sharing can be achieved if police provided mobile phones and airtime to CPC members especially the ones in charge of security at cell and village levels". Participant P3, noted that… "To train people living in Rwanda about information sharing, where to report, how to report, and also to have police officers assigned to analyze the information reported". Participant P4, observed that… "To re-energies CPCs at village level because some of them have left the committee and there was no replacement and those present some of them are not motivated". Participant P6, cited that… "There is a need for police to improve on sensitization for citizens to know their role in community policing because some do not understand this concept of community policing". Participant P7 reiterated that "Police should be attending cell meetings like "akagoroba kababyeyi" referring to parents' evening meetings to know what citizens are going through if there are any security challenges and advise them". He recommended the need to provide communication equipment like telephones to easily communicate and to adopt modern technology. Participant P11 observed that… "police should provide security equipment like CCTVs, handcuffs, water cannons and motivating police officers by increasing their salaries, and other incentives". --- Responses from focus group discussions by community leaders The religious leaders were asked their opinion on whether information sharing as a community policing strategy has been successful in reducing cases of crime and insecurity within the GASABO district. One of the discussants, D11 opined… "Indeed, as we said before, because of different online platforms, information sharing has become easy, a thief can commit a crime here in one village and because of this strategy of using the Village WhatsApp platform, SMS, and phone when he/she goes to hide in another village, he/she can be easily apprehended" Another discussant D12 observed that … "There is a thing that police have introduced to the public which is making their Toll-free lines address to be known everywhere by everyone and this has helped in reducing crimes. This has brought a positive impact because in every situation a citizen will not hesitate to call the police hence reducing a number of crimes" Further, discussant D14 stated that … "Information sharing has helped in crime reduction, road accidents have reduced, family issues have also reduced, theft in villages have reduced all these are coming out of this strategy of information sharing" The university lecturers, secondary and primary school teachers also supported the role of information sharing in enhancing security. Discussant D6 opined… "Yes, information sharing has played a big role in reducing crimes. A good example is that citizens share with police information on people who are engaged in drug trafficking. It is going to help police in fighting against those people and in return there will be crime prevention" Discussant D7 observed that … "Concerning information sharing, it is also an issue whereby it will depend on the nature of the crime committed. At times you may give out information to the police and they hold you until the investigation --- Journal of Humanities and Social Science Research Vol: 2, Issue: 4 July-August/2023 DOI: http://dx.doi.org/10.47742/jhssr.v2n4p1 https://jhssrnet.com/index.php/jhssr is over. As we said before there should be effective means that will allow people to give information when they are safe". --- Regression Analysis The study sought to determine the influence of information sharing on security enhancement. A simple linear regression was performed to examine the influence of information sharing on security enhancement. The model summary results are shown in Table 4. --- Table 4: Model summary for information sharing and security enhancement Table 4 presents R and R square values for the coefficient of correlation and extent of variation respectively for information sharing on security enhancement. The R-value of 0.566 indicates a positive association and this implies a fairly moderate level of correlation between information sharing and security enhancement. The R-square value of 0.321 explains that 32.1% of the security enhancement is contributed by information sharing. The remaining 67.9% of the security enhancement variation could be explained by other factors other than information sharing. In addition, Table 4 above shows that there is no autocorrelation or the residuals are uncorrelated as the Durbin Watson is 1.933 . Moreover, to validate the regression analysis, the histogram and P-P plot presented in Figure 4 shows reasonable normality of data. --- Figure 4: Histogram and P-P plot for information sharing and security enhancement The validity of the model in Table 4 is also validated using Analysis of Variance and results are shown in Table 5. Table 5: ANOVA test for information sharing and security enhancement Table 5 demonstrates the analysis of variance test and shows a positive significant relationship between information sharing and security enhancement . This confirms that information sharing significantly predicts security enhancement. The regression coefficient results are presented in Table 6. --- Table 6: Regression coefficients for information sharing and security enhancement As indicated in Table 6, the statistical coefficients of information sharing on security enhancement showed that the value of the unstandardized coefficient was 0.516 . This implies that information sharing is significantly predicting security enhancement. The linear regression model equation is presented as follows; Y= 2.102 +.516X4 Where; Y = Security Enhancement X= Information sharing From this equation, the model predicts that when information sharing is zero, the security enhancement is 2.102. It also predicts that for a one-unit increase in information sharing, security enhancement increases by 0.516 units holding the other predictors fixed. The study findings corroborated Muteti et al. conclusion that information sharing was a key determinant of effective community policing for enhanced security. Similarly, results supported Headayetullah et al. assertion on the significance of information sharing in enhancing security. Mixing and Interpreting of Quantitative and Qualitative Data Data on information sharing and security enhancement was analyzed using descriptive, thematic, and inferential methods. From the descriptive point of view, the majority of the respondents observed that information on community policing is shared through social media, information on community policing is shared through music, information on community policing is shared through word of mouth, information on community policing is shared through acting and information on community policing is shared through training. The thematic analysis had similar results where participants supported the role of information sharing in security enhancement. Further, inferential statistics revealed a similar outcome that a positive and significant association exists between information sharing and security enhancement. The statistical coefficients revealed that information sharing had a positive and significant influence on security enhancement in Gasabo District, Rwanda . --- Discussion of the Findings The study findings established that most of the respondents agreed that information on community policing is shared through social media , information on community policing is shared through music , information on community policing is shared through word of mouth , information on community policing is shared through acting , and information on community policing is shared through training . The findings imply that information sharing on community policing is done using various channels. Most of the respondents had positive opinions towards information sharing. Therefore, information sharing is expected to positively influence security enhancement. According to Braga and Tucker , the use of information systems has been emphasized to identify and analyze the problems faced by the community. The R-value of 0.566 indicates a positive association and this implies a fairly moderate level of correlation between information sharing and security enhancement. The R-square value of 0.371 explains that 37.1% of the security enhancement is contributed by information sharing. The statistical coefficients of information sharing on security enhancement showed that the value of the unstandardized coefficient was 0.516 . This implies that information sharing is significantly predicting security enhancement. The study findings corroborated Muteti et al. conclusion that information sharing was a key determinant of effective community policing for enhanced security. Similarly, results supported Headayetullah et al. assertion on the significance of information sharing in enhancing security. The findings of this study address various research gaps as pointed out in chapter two. Firstly, the contextual gap was addressed since this study concentrated on the Rwandan context. Secondly, the conceptual gap was addressed since this study examined the relationship between information sharing and security enhancement. Finally, the methodological gap was addressed since this study employed mixed methodology. This study also confirms the theoretical prediction of securitization theory and social disorganization theory that linked information sharing as a component of community policing to security enhancement. --- Conclusion The study concluded that information sharing had a positive and significant influence on security enhancement in Gasabo District, Rwanda. This implies that information sharing contributes significantly to security enhancement in Gasabo District, Rwanda. The key aspects of focus in information sharing were information sharing through social media, music, word of mouth, acting, and training. --- Recommendations The study recommended the need for RNP to strengthen information sharing for security enhancement. In particular, the institution should focus on enhancing information sharing aspects including information sharing through social media, music, word of mouth, acting, and training. It was also recommended that RNP should provide secure pathways for information sharing from citizens such as guaranteeing security of informants.

In Rwanda, in the aftermath of the 1994 genocide against Tutsi, the security situations were critical and the government adopted mechanisms such as community policing as a strategy for security enhancement. However, the country still struggles with insecurity challenges despite the introduction of community policing. The purpose of this study was to determine the influence of community policing information sharing on security enhancement in Gasabo District, Rwanda. The study adopted a mixed methodology approach and a concurrent triangulation design. The study targeted approximately 139,358 household heads of Gasabo District, 73 Community Policing Committee (CPC) chairpersons, 15 Community Liaison Officers, and 260 Police Officers. The study sampled 576 household heads for quantitative data whereas the CPC chairpersons, Community Liaison Officers, Police Officers, and Opinion leaders were used for qualitative data. A multistage sampling technique was used to select the participants. Questionnaires, interview guides, and discussion guides were used to collect data. The findings indicated that information sharing had a positive and significant influence on security enhancement. The study concludes that information sharing contributes significantly to security enhancement in Gasabo District, Rwanda. The study recommended the need for RNP to strengthen information sharing for security enhancement. In particular, the institution should focus on enhancing information sharing aspects including information sharing through social media, music, word of mouth, acting, and training.

cultural forces reward more gender-traditional behavior. Few studies that assess the importance of increasing numbers of primary earning mothers or primary caregiving fathers actually compare men and women within each of these social roles, such as comparing the experiences of stay-at-home fathers to similarly-situated stay-at-home mothers. Second, our focus on at-home fathers and breadwinner mothers centers our analysis on exactly those individuals who appear to deviate from more general patterns in, especially, previous housework studies. By honing in on these individuals and contrasting them with parents who are in the same family structure, but who are not deviating from culturally prescribed gender roles, we contribute to broader understanding of the relationship among time availability, relative earnings, and gender in shaping the household division of labor. We argue this focus enriches development of theory aimed at identifying mechanisms of change in gendered social systems. --- THEORY AND HYPOTHESES Relative Differences in Time and Money in Heterosexual Couples Previous theorizing on the household division of labor points to the importance of both time and money differences in heterosexual couples in shaping allocations to paid and unpaid work . Time is a finite resource, and, in general, more time in employment means less time for either child care or housework among parents. Since mothers, on average, are less likely to be employed at all and, when employed, to work fewer hours, research generally finds that mothers spend more time engaged in housework and child care than fathers . Previous work also finds that fathers respond to increases in women's work hours by doing more housework and more child care . Thus, differences in paid work commitments are important in shaping who does what at home. Money differences within heterosexual couples also matter. Bargaining and exchange theories posit that relative differences in earnings influence couples' decisions about dividing responsibilities for housework and child care duties between spouses. In particular, these theories suggest that relative earnings differences are indicative of power differences in couples that enhance the bargaining position of the higher-earning spouse . When coupled with the assumption that most people would prefer not to engage in domestic labor , a relative resources perspective predicts that the couple member with higher earnings will have enhanced bargaining power to negotiate less involvement in unpaid domestic work than a lower-earning spouse. In families with just one employed member, like those we study here, a relative resources perspective would predict that the full-time employed parent would do much less housework or child care than the nonemployed parent, regardless of the gender of the employed or at-home parent. Relative Resources and Housework-Support for the relative resources perspective is best demonstrated in studies examining how earnings differences among men and women shape housework time in the context of heterosexual relationships ). Consistent with the role of relative resources in bargaining processes, many studies find that individuals with higher relative earnings do less housework. However, multiple studies have noted deviations from this general relationship that inform research on, especially, couples with an at-home father or breadwinner mother. First, some studies find that men with lower earnings than their wives do less housework , even though women with lower relative earnings tend to do more housework than their higher-earning male partners. In addition, research focused on the role of unemployment on housework time finds that unemployment is generally associated with more time in domestic labor than employment and unemployed women's domestic contribution increases at twice the rate of unemployed men's contribution . These patterns may be important for understanding whether and how gender shapes non-employed at-home parents' time in domestic work. Second, some studies find a curvilinear relationship between a couple's relative earnings and housework time for women in that higher relative earnings lead to less housework up to a point, but once a woman is a primary earner, she does more housework despite higher relative earnings . This finding has been criticized as a "statistical artifact" that is related to a relationship between women's relative and absolute earnings. Since breadwinner women generally have lower earnings than women in couples with more equal relative earnings, their housework time may reflect their more precarious labor market position rather than serving as an indicator of increased bargaining power within the family. Further study of families in which wives are absolute earners, such as those with a full-time working mother and at-home father, contrasted with breadwinner fathers/at-home mothers may help clarify the role absolute earnings differences play in shaping the household division of labor. Relative Resources and Child Care-Evidence supporting a bargaining process that shapes the relationship between relative earnings and time in child care is not as clear as evidence of bargaining in housework . One difference between these two categories of domestic work is that the assumption that individuals prefer not to engage in domestic work is better supported in the case of housework than for child care activities . Child care generally gets rated more positively than housework, and both mothers and fathers report similar levels of enjoyment around caring for children . There may also be a stronger sense of future investment that motivates parental care in ways that differentiate it from housework . In general, studies looking at mothers' and fathers' share of child care time find mixed support for the role relative resources play in shaping child care time. Some studies find that time in care activities increases in response to a partner's work hours, others do not . Child care time also appears to be patterned in ways that may be more indicative of the importance of cultural differences than relative bargaining position within heterosexual couples . While parents' overall time in child care has been increasing over the last fifty or so years, child care time has increased most dramatically among the most educated parents . Given the positive association between education and earnings, this suggests that higher-earning parents are also the parents most likely to be highly engaged in child care. It is not clear that higher relative earnings within heterosexual couples will result in less time engaged in child care, particularly when mothers have the income advantage . Indeed, time with children has gone up among mothers even as they have increased their paid work involvement , and it has gone up the most among the most educated mothers and fathers . Along these lines, at least three recent studies drawing on the ATUS find that mothers' time in child care is not linked to relative resources differences in ways suggested by bargaining or exchange processes. Connelly and Kimmel utilize ATUS data from 2003-4 and find that mothers' time in child care is not influenced by relative wage differences, although fathers' child care time is negatively related to mothers' wages. In addition, Raley et al , drawing on 2003-7 ATUS data, find that while there is some evidence of association among relative differences in earnings and time with children in ways that are consistent with a relative resources perspective, mothers who earn more spend more time with children after controlling for work hours. Finally, England and Srivastava draw on 2003-11 ATUS to investigate the influence of education level of mothers and fathers on parents' child care time. They conclude that highly educated parents do more, not less, child care than those with lower educational attainment. These current studies provide little evidence that parents use bargaining power to reduce time in child care. --- Mothers, Fathers, and Domestic Work: A Gender Perspective While time or power differences between men and women in heterosexual relationships do appear to shape the division of unpaid domestic labor in some cases, as our review shows, there are important contexts in which who is available or earns more, or at all, is not associated with doing less domestic work in ways predicted by a time availability or relative resources explanation. In particular, where we see the relationship between higher relative availability and earnings and less time in domestic work breaking down most often is in couples with unusual family forms, such as those families containing an unemployed man or a woman with very high relative earnings. These patterns suggest that the gender of the nonemployed person or of the dominant family earner also shapes decisions and behavior regarding time in domestic labor. Scholars who study gender in the context of work and family life argue that a range of cultural and institutional forces limit the influence of bargaining processes rooted in time availability and relative earnings differences when it comes to allocating time to domestic tasks. For example, in spite of enormous changes in women's paid work involvement, the idealized, culturally normative model for work and family continues to be centered on a breadwinner/care giver ideal in which breadwinners are men and care givers are women . Previous research indicates that breadwinning itself is inextricably linked to hegemonic masculinity and tightly connected to dominant cultural images of "good" fatherhood . Similarly, "good" mothers, especially those who are white and well-educated, face social pressure to engage in time-and attention-intensive parenting practices . In addition, research consistently indicates that many parents are judged based on how well they conform to traditional work/ family roles . Those parents who deviate from these traditional roles face negative social judgement . Institutional practices built around this idealized and gendered male breadwinner/female care giver model may influence parents' time in domestic tasks . Institutions such as schools, health care facilities, or community centers may be "gendered" in the sense that they reach out to or support the parents they assume are most involved in children's care, often mothers. Further, an institutionalized gender gap in earnings places more financial strain on families headed by a female breadwinner, leading to greater pressure for male at-home parents to look for paid work rather than to engage in domestic tasks. This might also limit female breadwinners' bargaining power with respect to domestic work if their relative earnings "dominance" is considered more temporary than it might be in at-home mother/breadwinner father families . Taken together, previous research and theorizing supports the idea of a gendered breadwinner/care giver ideal that is still influential in shaping cultural and institutional practices that limit deviations from traditional work/family roles. Cultural sanctioning processes and institutional practices rooted in a more traditional family model may restrict at-home fathers' domestic involvement while also limiting breadwinner mother's ability to disengage from domestic work, in spite of high relative earnings. --- Domestic Work in Gender-Atypical and Gender-Traditional Families Investigations of families with an at-home or breadwinner parent provide mixed support for the role of time availability and bargaining as factors shaping domestic work time in these family contexts. Studies indicate that the transition to at-home fatherhood is associated with greater engagement in housework and, especially, child care , although there may be large variation in how much more housework at-home fathers actually take on . Other research suggests that athome fathers tend to step up their involvement in more traditionally male housework tasks, like remodeling or painting projects , but may not do much more in the way of routine housework, suggesting that gender conditions, especially, housework time. Research on contemporary breadwinner father/at-home mother families suggests that breadwinner fathers rely on at-home mothers to complete the bulk of child care and housework tasks and report very little involvement in any domestic work , consistent with both time availability and bargaining expectations, as well as gender role expectations. Finally, one recent study with an explicit focus on the division of labor in athome father families finds that the timing of who engages in domestic work shifts such that at-home fathers do the bulk of domestic work when mothers are on the job, but domestic workloads shift back to breadwinner mothers after work and on non-work days , raising doubts about improvements in breadwinner mother's bargaining power related to their higher earnings or reduced availability. --- Hypotheses Both time availability and relative resources perspectives predict that individuals who work more or greatly out earn spouses will report less time in domestic work. This process appears to be generally supported in studies of housework time, although findings for "atypical" families, such as those with a non-working man or a woman with high absolute earnings are mixed. There is less clear support for these processes when time in child care is considered. If time availability and relative earnings in couples are the dominant factors shaping time allocations to domestic work, we would expect: H1: Breadwinner parents will spend less time in housework and child care than athome parents. H2: There will be no difference in housework or child care time when breadwinner mothers are compared to breadwinner fathers. H3: There will be no difference in housework or child care time when at-home mothers are compared to at-home fathers. However, if gender constrains bargaining power for mothers in gender-atypical work-family roles by pushing mothers into housework and child care tasks, then we would expect: H4a: Female breadwinners will spend more time in housework and child care than male breadwinners, all else equal. In addition, gender effects on time in domestic work may be stronger for employed mothers than fathers . Put differently, we might expect that the constraint of work hours is weaker for breadwinner mothers than fathers. Thus, a related hypothesis considers gender differences in domestic work for breadwinners based on daily work hours: H4b: Female breadwinners will spend more time in housework and child care than male breadwinners, given the same daily work hours. Further, if gender constrains the involvement of fathers in both housework and child care, as well, we would also expect that: H5: At-home fathers will do less housework and child care than at-home mothers. H6: Time in child care and housework will be more similar among at-home fathers and breadwinner mothers than among at-home mothers and breadwinner fathers, all else equal. We test these hypotheses drawing on a sample of at-home and breadwinner parents from the 2008-12 ATUS. Our hypotheses are grounded in explanations that emphasize the role that couples' relative time and earnings play, essentially focusing attention on how similar structural conditions shape time use, and contrast these expectations with others that indicate that gender is a critical factor shaping involvement in unpaid domestic work among heterosexual parents, even when important structural conditions are held constant. We investigate parents with the most extreme time and earnings differences because these appear to be cases in which the relationship among time availability, clear relative earnings differences, and less involvement in domestic work sometimes break down. This focus allows us to contrast the experiences of those who tightly conform to or clearly deviate from prevailing gendered work/family cultural ideals because research suggests that these are the cases in which the role of entrenched individual, cultural, and institutional gender-based work/family practices should be most evident. --- METHOD Data We analyze American Time Use Survey data to test our hypotheses . The ATUS is a nationally representative time diary study of Americans. Data are collected using a computer assisted telephone interview , and the respondents report the activities they engaged in over a 24-hour period from 4:00 a.m. of a specified day until 4:00 a.m. of the following day as well as where, when, and with whom activities were done. Data are collected all days of the week, and weekends are oversampled. Sample weights correct for the survey design such that aggregating across different days of the week results in a representative picture of average time use among the population. Our results are based on pooled cross-sections from 2008 to 2012. We limit our sample to these years to incorporate a key measure of physical difficulty that is only available for ATUS respondents and their spouses beginning in 2008. ATUS sample members are invited to complete the survey following exit from the Current Population Survey . The CPS is a household survey of the civilian, noninstitutionalized population. One individual aged 15 or older per former CPS participating household is randomly selected to participate in the ATUS during the two to five months following their household's CPS exit. ATUS response rates were over 50% for each of the survey years . Fatigue is the most common reason for ATUS nonresponse, which is a result of using CPS as the sampling frame . Nonresponse bias in the ATUS is not problematic except in studies that examine time in volunteer activities . The 2008 to 2012 ATUS data include daily diary entries of 64,038 civilians age 15 and older. Despite the one member per household design, the ATUS collects demographic and employment information about spouses which allows us to identify at-home and breadwinner parents based on usual hours worked and to incorporate select couple-level measures in our analysis. We first restrict our sample to heterosexual married respondents with a spouse who was co-resident at the time of the CPS and with one child under 18 in the household . Our focus on at-home and breadwinner parents based on usual hours worked excludes individuals in couples without an earner and in dual-earner couples . These 5,505 records are further reduced to 4,633 because the respondent/spouse physical difficulty measures are not available until August 2008 . --- Measures Family definition-All respondents are individuals in a couple where one member usually works for pay and the other member does not. The at-home and breadwinner mothers and fathers in our sample are not married to one another. Our family definition is based on both the respondent's and his/her spouse's usual hours worked per week . A respondent is classified as "at home" if he/she does not work for pay and has a spouse who usually works 35 or more hours per week. A "breadwinner" is a respondent who usually works 35 or more hours per week for pay and has a spouse who does not work for pay. --- Dependent variables- We analyze two sets of dependent variables: minutes in housework and minutes in child care. The majority of our dependent variables measure minutes on the diary day spent in the primary activity at hand; we note the instances where non-primary activity information is used to create a dependent variable. We distinguish between three types of housework-female-typed, male-typed, and gender-neutral . Female-typed household activities are routine and are done almost daily whereas male-typed household tasks are irregular and done less frequently . Female-typed housework includes activities such as interior cleaning, laundry, and meal preparation . We classify activities such as home maintenance, yard work, and vehicle repair as maletyped housework. Gender-neutral activities include caring for animals, household management, and organizational activities. Primary child care activities include playing with children, physical care of children, and other child care-related activities such as education, transportation, and doctor's visits. ATUS also collects information from respondents with a co-resident child under 13 in the household about secondary child care and who the respondent was with during the activity . These data allow us to consider parental child care time more broadly and analyze time spent in secondary child care and time spent with children. The time spent in secondary child care measure indicates the minutes the respondent is available to provide immediate assistance to a child while he or she is not performing direct child care. Time spent with children is the minutes spent with household children based on the respondent's report of who he/she was with during each activity and taps physical proximity and joint engagement in activities. In the cases of secondary child care and being with children, we are indifferent about the primary activity respondents report; the result is that these variables effectively "overlap" time spent during primary activities such as leisure and housework. Independent variables-We control for the husband's and wife's age given previous research that at-home fathers tend to be older than breadwinner fathers . Drawing on information about spouses, we include couple-level measures of education and race. Both are important because educational differences condition employment choices and race can shape one's ability to enact preferences for more traditional gender roles . Education categories include both have a college degree , neither has a college degree, wife has a college degree but husband does not, and husband has a college degree but wife does not. Race is coded as both white , both nonwhite, and white/non-white couple. We also control for breadwinners' daily work hours since differences in work hours on the diary day among parents likely shape their time availability for other activities and tend to be higher for fathers than mothers . In addition, we control for at-home spouses' employment intentions. We consider at-home respondents and spouses as intending to find work if individuals are: 1) non-workers who have been looking for work during the past four weeks; 2) non-workers who intend to look for work during the next year; or 3) currently unemployed individuals who are either looking for work or on layoff. We also include an indicator of retirement for non-working respondents and spouses. Because health limitations may be an important factor shaping athome fathers' unemployment as well as the ability to engage in domestic work, we incorporate two dichotomous variables indicating physical difficulty defined as difficulty engaging in personal care, having mobility limitations that are not temporary, or having serious difficulty walking/climbing stairs. Individuals who indicate that they have one or more of these conditions receive a "1" on the physical difficulty measure. We control for family income distinguishing among < $25,000, $25,000-$49,999, $50,000-$74,999, and $75,000+ . Since numbers and ages of children in a residence can add to the housework and child care burden, we also include a range of controls aimed at parsing out the effects of children on time in domestic work. These include controls for the number of own co-resident children under 18 and the age of the youngest own child in the household as well as the presence of an infant in the household, whether the respondent has an own non-residential child, and whether a non-own child under 18 resides in the household. Additional covariates include whether the respondent reported about a weekend or weekday and the year of data collection where 2008 is the reference. Tables 1 and2 contain the means for all of the measures used in this analysis by whether the ATUS respondent is an at-home or breadwinner mother or father. --- Analytic Strategy The often large number of zeros in time diary data along with the fact that time spent in one activity is not independent of time spent in another has led to disagreement about appropriate modeling strategy in time use studies. There is evidence that OLS models produce less biased estimates than Tobit models , even if the models produce qualitatively similar results . As a result, many contemporary studies successfully employ OLS regression to model time spent in specific activities, like child care . This is our approach here. We estimate eight separate OLS equations and conduct a series of post-hoc significance tests to evaluate differences in time among different sets of parents, comparing time in female-typed housework among at-home mothers and at-home fathers, for example. We use these significance tests to assess evidence to support our hypotheses. To aid interpretation, we also produce a table of predicted minutes among our parents on weekdays in each of the eight domestic activities under study . These predicted minutes are calculated by holding all categorical variables at the reference category. All continuous variables are held at the sample mean, except for daily paid work hours, which is set at 0 and 8 hours to estimate minutes on a nonwork day and the traditional "full-time" work day. An additional analytic issue concerns the dependencies across activities in a day that suggest that the assumption of uncorrelated error terms necessary to perform a series of separate OLS regressions may be violated when time across different activities is examined. Indeed, tests of correlated error terms in these data indicate that this assumption is not met here. To investigate whether this problem influenced our findings, we also estimated our models using Seemingly Unrelated Regression . SUR allows us to simultaneously estimate our eight equations while relaxing the assumption of independent error terms. This approach has been used in other studies that estimate multiple models of time spent on related activities . Because we do not vary the independent variables in our models across equations, our SUR models reduce to OLS models in practice. Any deviations between our SUR and OLS models occur because of differences in how STATA handles weights across both sets of estimations. The SUR exercise suggests that our substantive conclusions are generally robust to choice of modeling technique . Missing Data-Our analytic sample contains 206 cases with missing income data. We conducted an attrition analysis to examine whether missing data might influence our substantive findings . This analysis suggests that couples' education is significantly related to missingness. Because education is an important characteristic shaping time in domestic work , we use multiple imputation to retain these cases in our sample. Multiple imputation is considered one of the best tools to deal with problems of missing data in statistical analyses . We estimated all of our models using the imputed sample and the sample where missing income cases are omitted . Our substantive conclusions do not change across these two sets of analyses. We present results using imputed data here . --- RESULTS Table 1 documents descriptive statistics for the sample by family type. Fathers tend to be older than mothers, but the age gap is larger among individuals and spouses in genderatypical couples than among individuals in gender-traditional families. The proportion of individuals who report that they and their spouse are college educated is higher among respondents in gender-traditional than gender-atypical arrangements. Just under 30% of stay-at-home mothers and breadwinner fathers report that they and their spouse both have a college degree. This is true of about 20% of stay-at-home fathers and breadwinner mothers. In addition, the majority of respondents in gender-traditional arrangements report that both they and their spouse are white, while just over half of individuals in gender-atypical family arrangements report being in mixed race or non-white couples. Although all breadwinner parents are employed full-time, breadwinner fathers report slightly higher daily work hours than mothers on days they work. It is also interesting to contrast the work intentions among at-home parents. About twice as many at-home fathers report that they are looking for or intend to find work compared to 27% of athome mothers. Similarly, higher proportions of breadwinner mothers are married to spouses who are looking or intend to find work than breadwinner fathers . More athome fathers than at-home mothers report being retired. Similarly, more breadwinner mothers than fathers report being married to a retired spouse. Among at-home fathers, 13% report having one or more physical difficulties compared with 3% of at-home mothers. However, while breadwinner fathers' reports of spouses' difficulty largely match the rates reported by at-home mothers , breadwinner mothers report lower rates of physical difficulty among their spouses . Very few breadwinner parents report having a physical difficulty. Incomes also vary by family type. Smaller proportions of both at-home fathers and breadwinner mothers report family incomes of $75,000 or higher compared with at-home mothers and breadwinner fathers . Athome father and breadwinner mother households have fewer children in the home than athome mother and breadwinner father households . Further, the children in athome father and breadwinner mother households are older, on average, than those in athome mother and breadwinner father households. While infants are rare in most families, slightly more at-home mothers and breadwinner fathers report having an infant at home when compared with at-home fathers or breadwinner mothers . The presence of non-residential children is also relatively rare across family types, and few parents report having a non-residential child or a child not their own in the home on the diary day. Overall, the patterns in Table 1 indicate that households with an at-home father or breadwinner mother have similar demographic profiles as do households with an at-home mother or breadwinner father. However there are clear demographic contrasts in the racial/ ethnic makeup of couples, in educational levels, in income, and in rates of physical difficulty among other things across individuals in gender-atypical versus gender-traditional workfamily arrangements. Table 2 lists the proportion of parents engaging in a range of housework or child care tasks at all on a diary day as well as the mean minutes per day by family type. The descriptive patterns suggest that housework is traditionally gendered such that at-home mothers do more housework than at-home fathers and breadwinner mothers do more housework than breadwinner fathers. These descriptive patterns support the gender constraints hypotheses as opposed to the time availability and relative earnings hypotheses . The descriptive data also show that at-home parents do more housework than breadwinner parents, which is consistent with expectations of time availability and relative resources . Fathers do more male-typed housework than mothers while mothers do more female-typed housework than fathers when similarly-situated parents are compared. Overall, the amount of time spent in female-typed tasks tends to be greater than in male-typed tasks and higher proportions of mothers compared to similarly positioned fathers engage in any housework on diary day. The descriptive patterns in housework time appear to highlight the importance of gender over time availability or bargaining power linked to high relative or absolute earnings in shaping time in housework in these families. In terms of child care time, patterns are traditionally gendered in that at-home mothers spend significantly more time in child care tasks than at-home fathers , which is consistent with gendered parenting expectations that favor mothers. However, the small time differences among breadwinner parents are not significant, which is not what we would expect if gendered parenting expectations were pushing mothers into greater levels of child care than fathers. Table 2 also illustrates that at-home parents spend more time engaged in secondary child care and in overall time with children than breadwinner parents. Again, this pattern supports both time availability and relative resources explanations. We do see significant differences in the time spent on these activities across at-home parents. At-home mothers spend more time on secondary child care and in overall time with children than at-home fathers while breadwinner parents are similar in time spent on these activities. These descriptive results provide a somewhat mixed picture. Time availability or relative resources matter, since at-home parents clearly do more child care than breadwinner parents . Similarly, we see no differences among breadwinners in the descriptive child care pattern, which supports a time availability/relative resources explanation over a gendered constraints explanation . However, gender differences within at-home parents persist, as at-home mothers spend more time on child care than at-home fathers, which supports the hypothesis that emphasizes the role of gender over time availability and resource differences . --- OLS Results: Housework Our regression results build on previous work to highlight greater nuance in the relationship between work/family role and housework time. If time availability and earnings-based bargaining power shape housework time, we would expect to see that breadwinner parents consistently do less housework than at-home parents , controlling for a number of demographic and other differences that separate these individuals. This is what we see when comparing fathers. The regression results document that at-home fathers do more femaletyped housework than breadwinner fathers on breadwinner fathers' non-work days. Table 4, which provides differences in predicted minutes in specific housework and child care tasks, illustrates that these significant differences in female-typed housework time among fathers are larger on days breadwinner fathers work. We do not detect differences in time spent on male-typed or gender-neutral housework among fathers on breadwinners' non-work days, but post-hoc tests indicate that at-home fathers do more of both types of housework than breadwinner fathers on days breadwinners work . We see different patterns when we compare mothers. Because breadwinner fathers are the comparison group in Table 3, we identify time differences among at-home and breadwinner mothers on breadwinner mothers' non-work days by looking at the difference between at-home and breadwinner mothers' regression coefficients. To assess whether these differences are statistically significant requires additional post-hoc tests, which we conduct and report. For example, the estimated time difference in female-typed housework among at-home and breadwinner mothers on non-work days is about ten minutes . Post-hoc significance tests indicate that, on breadwinner mothers' non-work days, their time in female-and male-typed housework is indistinguishable from at-home mothers', although at-home mothers spend more time in gender-neutral housework than breadwinner mothers. 1 However, on days breadwinner mothers work, they do significantly less of all types of housework than at-home mothers. Thus, we see one indication that time availability and earnings shape housework time in different ways for breadwinner mothers versus fathers. Work hours constrain breadwinner mothers' housework time on days they work in all types of housework, but on days they do not work, they look just like at-home mothers with respect to time in female-and male-typed housework. However, paid employment is associated with less housework involvement among breadwinner fathers when compared to at-home fathers, even on days breadwinner fathers are not working. Overall, the expectation that breadwinner parents consistently do less housework than at-home parents rooted in time availability and relative resource explanations is supported for fathers but only partially supported for mothers. Time availability and resource-based bargaining are expected to work in the same way when we compare male and female at-home parents and male and female breadwinner parents . Despite our expectations of no differences among similarly-situated mothers and fathers, this is not what we observe. We compare housework time among breadwinner parents directly by looking at the regression coefficients displayed in Table 3. The significant coefficients for breadwinner mothers indicate that breadwinner mothers do more female-typed housework and less male-typed and gender-neutral housework than breadwinner fathers on non-work days, contrary to H2. Additional post-hoc tests reveal that differences in female-typed housework and male-typed housework are also significant when breadwinner mothers and fathers work eight hours; this is not the case, however, for gender-neutral housework. Predicted minutes illustrating these patterns on non-work and work days are displayed in Table 4. There is also evidence of a significant interaction between type of work/family arrangement and breadwinners' daily work hours . This interaction indicates that the gap in female-typed housework or male-typed housework shrinks as breadwinners work more hours and is more responsive to work hours for breadwinners engaging in gender-normative tasks. The overall pattern documents strong gender-normative tendencies around housework for breadwinners. Breadwinner mothers do more female-typed housework than similarly-situated fathers, even when daily work hours are high. Similarly, breadwinner fathers do more male-typed housework than breadwinner mothers, even when daily work hours are high. However, the predicted time differences in 1 The SUR models suggest that mothers' housework time is indistinguishable across all types of housework tasks on breadwinner mothers' non-work days. The OLS models consistently show that at-home mothers do more gender-neutral housework on breadwinner mothers' non-work days. female-typed housework appear to be much larger than they are for male-typed or genderneutral tasks, suggesting that these trends may result in a higher overall housework time for breadwinner mothers than fathers, even on work days. Thus, these patterns provide support for explanations that emphasize the role that gender plays in constraining counter-normative domestic behaviors , although they also point to general reductions in housework time that appear linked to time availability for all parents . We also see evidence of gender-based housework specialization among at-home parents. Athome mothers do more female-typed housework than at-home fathers , while athome fathers do more male-typed and gender-neutral housework than at-home mothers. Supplemental analyses examining differences in total housework time indicate that at-home mothers spend more time on housework overall than at-home fathers . These patterns provide further support for the expectation that gender constrains or enables housework involvement among similarly-situated parents more than time availability and earnings-based bargaining power explanations in shaping housework time . While the respondents in our sample are not married to one another, they are likely married to at-home and breadwinner parents similar to those in our sample. Our last hypothesis focuses on comparisons among gender-atypical parents and gender-traditional parents . Among parents in gender-atypical arrangements, at-home fathers do more male-typed and gender-neutral housework than breadwinner mothers, regardless of breadwinner mothers' time in paid work. However, differences in time spent in female-typed housework vary greatly by breadwinner mothers' paid work time. On breadwinner mothers' non-work days, these mothers spend substantially more time engaged in female-typed housework than at-home fathers . However, on days breadwinner mothers work, at-home fathers do an estimated 33 more minutes of female-typed housework than breadwinner mothers . Among breadwinner fathers and at-home mothers, we see similar patterns in terms of gender-normative housework. On non-work days, breadwinner fathers spend substantially more time engaged in male-typed housework activities than at-home mothers . This gap shrinks to non-significance on days these fathers work. However, at-home mothers do substantially more female-typed housework than breadwinner fathers on fathers' non-work days . This gap widens on days breadwinner fathers work at least 8 hours . Overall, these results highlight the importance of gendered housework specialization that is not eliminated by time availability or resource-based bargaining processes. They also suggest a link between gender and housework that is evident when we compare parents' housework time on breadwinner parents' non-work and work days. When everyone's time availability is high, breadwinner fathers do less than at-home fathers while both breadwinner and stay-at-home mothers engage in similar housework. However, when breadwinners' time availability is constrained, these patterns suggest time gaps in non-normative tasks may shrink across family types. --- OLS Results: Child Care Our results generally support the hypothesis that breadwinner parents spend less time on child care than at-home parents, as time-availability and resource-based bargaining would suggest . Among fathers, at-home fathers spend significantly more time engaged in children's physical care and education or other care than breadwinner fathers on breadwinners' non-work days. Differences among fathers in child care time are larger on days breadwinner fathers work. All these differences are significant . Similarly, at-home mothers spend more time playing with children, in education/other tasks, and more time with children overall on breadwinner mothers' nonwork days.2 These time gaps are evident across all areas of child care on days breadwinner mothers work. Consistent with time-availability and resourced-based bargaining , breadwinner parents spend less time caring for children than at-home parents, even on days breadwinner parents do not work. However, while at-home parents spend more time engaged in child care than breadwinner parents, we also observe differences in child care time among similarly-situated mothers and fathers, contrary to time availability or resource explanations . On non-work days, breadwinner mothers spend more time than breadwinner fathers engaged in children's physical care and educational and other care tasks . These differences are not large on non-work days, and are smaller when we compare breadwinner parents working an 8-hour day. By contrast, differences in overall time with children and secondary child care are markedly bigger among breadwinner parents on work days, with breadwinner mothers spending substantially more time in these ways than fathers. Playtime, however, is similar among breadwinner parents on work days. There is also evidence of an interaction effect that shapes time engaged in secondary child care at different levels of daily work time among breadwinner parents . All breadwinner parents reduce time in secondary care for each additional hour spent at work. At each level of daily work hours, though, breadwinner mothers engage in more secondary care than breadwinner fathers. Further, unlike the pattern for housework, the gap in secondary time is larger with longer work hours. Together, these results indicate that time availability and resourced-based bargaining are shaping time in child care in different ways for breadwinner mothers versus breadwinner fathers, which is more consistent with expectations that gender constrains employment influences on child care time . Similar to patterns among breadwinner fathers and mothers, at-home mothers spend significantly more time engaged in all child care tasks than at-home fathers, which does not support strict time availability or resource-based bargaining explanations but does support gender-based explanations . While statistically significant daily gaps in play time , physical care , and education/other tasks are not large, differences in overall time with children and in secondary child care are substantial. In sum, among similarly-situated parents, mothers spend more time engaged in child care than fathers, consistent with explanations that point to the role gender plays in enabling or constraining involvement with children . When we compare time in child care among gender-atypical parents and gender-traditional parents we see patterns that provide partial support for explanations that emphasize the importance of gender enabling/constraint . Comparing gender-traditional mothers and fathers, the patterns are clear. At-home mothers spend more time in every type of child care task than breadwinner fathers, regardless of whether breadwinner fathers are working or not . However, patterns for parents in gender-atypical arrangements vary by breadwinner mothers' work time. On breadwinner mothers' non-work days, we do not detect any significant differences in child care time. Both breadwinner mothers and at-home fathers appear to spend relatively equal amounts of time on a range of child care tasks on non-work days, which is different from patterns for parents in gender-traditional arrangements. However, on days breadwinner mothers work, child care divisions mirror those of individuals in gender-traditional arrangements, with the at-home parent doing significantly more of all types of child care than the breadwinner parent. --- DISCUSSION Our comparison of individuals in gender-atypical and gender-normative work/family arrangements highlights some of the nuanced ways in which time availability, resourcebased bargaining, and gender shape parents' domestic work. First, our results document important linkages between gender and parents' housework time. There is evidence of gender specialization in housework tasks; mothers tend to do more female-typed housework and fathers tend to do more male-typed housework, regardless of work status. However, gendered housework engagement is not impervious to structural constraints. Breadwinners do less gender-normative housework on work days, and gaps among breadwinner mothers and fathers shrink as daily work hours increase, suggesting that time availability plays a role in reducing gender differences in housework among similarly-situated parents. Our comparisons also suggest that at-home parents may do more gender non-normative household tasks on days their spouses work, although we cannot directly test this with individual-level data. It is this variation in housework on breadwinner parents' non-work and work days and the gender of the breadwinning parent that might be important in reconciling some of the mixed findings about how housework is divided among heterosexual couples in which women are high earners. Comparisons of at-home fathers' and breadwinner mothers' housework time show a tendency for breadwinner mothers to do more female-typed housework than at-home fathers on non-work days but less on work days. Similarly, breadwinner fathers do more male-typed housework than at-home mothers on non-work days but less on work days. However, most of our estimates indicate that time in female-typed tasks, especially for mothers, is an important driver of overall housework time. As a result, it may be counternormative behavior by at-home fathers around these female-typed tasks that shapes conclusions about how time availability, relative resources, and gender influence parents' housework time. In gender-atypical families, differences in housework time may depend on whether or not breadwinner mothers are working, while gender-traditional at-home mothers appear to do more housework whether breadwinner fathers are working or not. Thus, similar tendencies among working parents to do fewer gender-normative housework tasks on work days appear to be present across individuals. Yet, the potential to disrupt gendered housework patterns may be greater in gender-atypical couples than in gender-traditional couples because reductions in the size of female-typed housework gaps may have the greatest impact in terms of reducing differences in overall housework time. However, it may be difficult to consistently detect this pattern in analyses using measures of overall housework time and when analyses do not clearly account for variation on work-versus nonwork days across men and women. It is worth emphasizing that patterns on non-work days underscore the enduring power of gender-normative housework behavior. While all breadwinner parents appear to do more housework on their non-work days, at-home fathers do more female-typed housework than breadwinner fathers on breadwinner fathers' non-work days, while the housework time of athome and breadwinner mothers across most types of housework is indistinguishable on these days. That similarly-situated working parents have such different patterns suggests that mothers and fathers likely feel different housework pressures, in spite of similar structural positioning as full-time workers and high relative earners. When time availability is high, breadwinner mothers may act on these feelings or react to these pressures while breadwinner fathers do not. This is consistent with previous research that notes that women find greater meaning in housework compared to men and that mothers feel socially accountable for the appearance of their home . Qualitative research on gender-atypical couples also suggests that these couples engage in a "domestic handoff" on breadwinner mothers' non-work days . While the reasons for this handoff vary from allowing mothers to feel in control of domestic tasks to providing fathers a break from domestic work, these qualitative data support our time use findings that show that breadwinner women do more housework than at-home fathers on their days off. Further, research on contemporary breadwinner father/at-home mother families indicates that the general pattern in these families is that mothers take care of all household and domestic needs to support fathers' full-time work . This qualitative finding is certainly well-supported by the patterns in our analysis for individuals in gender-traditional couples. Other scholars have argued that processes shaping mothers' and fathers' time in child care are different from those shaping time in housework . Our results underscore these points and demonstrate that linkages among time availability, resource-based bargaining, and gender appear somewhat different in the child care context than they are in the housework context when comparing individuals in gender-atypical and gender-traditional families. Our child care patterns highlight the clear role of time availability in shaping working parents' engagement in their children's care . At-home parents consistently spend more time in different types of child care activities than breadwinner parents on days breadwinner parents work. It is also generally true that the gap in at-home versus breadwinner parents' child care time shrinks on days breadwinner parents are not working. Thus, both breadwinner mothers and fathers respond to work constraints in similar ways. They provide less care to children on days they work, relying on at-home parents for this care, and they step up involvement with children on their days off. These overall patterns are consistent with previous research that documents similar attitudes about the value of time with children across mothers and fathers . However, there are nuances in our comparisons of parents' child care time that point to the potential importance of gendered processes in shaping parents' engagement with their children. First, while the gap in time spent on child care tasks generally shrinks across individuals in both family types when we compare mothers and fathers in the same family type on breadwinner parents' work and non-work days, our findings point to more equal time investments on breadwinner parents' days off among parents in gender-atypical arrangements. Time in child care tasks across categories is indistinguishable among mothers and fathers in gender-atypical arrangements on days breadwinner wives are not working. Among individuals in gender-traditional arrangements, the child care gap among mothers and fathers is smaller on fathers' non-work days, but athome mothers still do more of some tasks . So, while breadwinner fathers' involvement in child care is higher on non-work days, they do not increase it with the same intensity breadwinner mothers do, particularly in the areas of children's physical care or educational and other tasks. Qualitative research examining contemporary breadwinner mothers' attitudes and experiences underscores that these mothers feel pressure to spend time with children that may be exacerbated by at-home fathers' heavy engagement in child care . Research also indicates that breadwinner mothers perceive more social judgement about their time with children than they think breadwinner fathers feel or experience . Both of these mechanisms could create greater pressures for breadwinner mothers, but not necessarily for breadwinner fathers, to increase their involvement with children when they are not working. Similarly, contemporary research on at-home fathers indicates that these fathers' greater involvement in their children's care generally can mean that children are more likely to turn to them first, even on days their mothers are available . Overall, the time at-home fathers spend caring for and cultivating relationships with their children coupled with the preferences and pressures breadwinner mothers may feel to remain highly involved in their children's care may lead to more equal childcare involvement in these families, even with big disparities in paid work involvement. As a whole, we suspect patterns in child care time across parents in gender-atypical versus gender-traditional family types highlight the importance of widely-held, gendered parenting norms that still place greater pressure on mothers than fathers to be heavily involved in the care of their children . While there is evidence that norms favoring greater child care involvement on the part of fathers are emerging, pressures on fathers still appear more limited relative to those shaping mothers' involvement . This may be particularly true for fathers in gender-traditional arrangements, where breadwinners are more likely to emphasize trade off time with children in favor of paid employment than fathers in dual-earner or at-home arrangements . Thus, gendered dynamics around work and parenting may create a different set of constraints for breadwinner mothers and fathers, with mothers feeling more pressure to be involved with children and fathers feeling more pressure to favor employment over time with children. Further, the clear expectation that at-home mothers are "in charge" of all things domestic in gender-traditional families may not translate when the at-home parent is a man . Finally, we emphasize that our descriptive results point to different demographic profiles of gender-atypical and gender-traditional families. These different demographic profiles suggest that it is families which are at greater risk for economic and social disadvantage that are in the gender-atypical group. Overall, these demographic patterns are consistent with previous studies that suggest that many families fall into gender-atypical work-family arrangements due, especially, to men's job instability rather than out of a strong desire to fulfill gender-egalitarian ideals . Gender theorists point to periods of economic or social disruption as sites for gender change . The tenuous commitment to a genderatypical family structure suggested by some previous studies and the large proportion of at-home fathers relative to mothers who report intentions to work in our research underscore that genderatypical family structures are likely short-term adaptations to economic challenge in many cases. In spite of this, we think our findings point to areas of potential disruption of gendered patterns that may reduce the influence of gender in shaping involvement in domestic work. First, parents in gender-atypical couples appear positioned to disrupt some gendered domestic patterns on days breadwinner wives work. While we know little about the potential for shifts in these circumstances, it may be that at-home fathers respond to breadwinner wives' employment by stepping up their involvement in tasks that are not gender-normative for them on breadwinner mothers' work days. Since it is "female" tasks that tend to make up the bulk of housework time for mothers, if this is happening, it could be evidence of positive change in the gendered division of domestic work. Additionally, while our findings document that gender continues to shape aspects of child care time in these families, employment is linked to smaller gender gaps in child care time among breadwinners when we compare them on both non-work and work days. When time availability is constrained, the influence of gender on child care time may be weakened. To the extent that both structural and cultural changes lead to more parents in genderatypical work/family arrangements, these exposures may position individuals to engage in more gender-flexible domestic behaviors. Engaging in more gender-flexible behaviors may also lead to the adoption of more gender-flexible attitudes . This study has several limitations that must be acknowledged in interpreting our results. First, the cross-sectional, one respondent per household design of the ATUS limits our ability to understand how gender and employment processes operate within couples under changing circumstances. Such an analysis would require longitudinal, couple-level data with information about time allocations in the context of changing work-family arrangements. We are not able to distinguish whether individuals with more egalitarian ideals about gender are more likely to choose gender-atypical arrangements or whether being in gender-atypical arrangements leads to more egalitarian behavior, although previous research and the demographic profiles evident in this study suggest that individuals with more gender-egalitarian ideals are not more likely to wind up in gender atypical-work family arrangements. Second, while the ATUS allows us to document differences and similarities in behavior among at-home and breadwinner parents, we are unable to distinguish between choice and constraint. We cannot know, for example, whether breadwinner mothers use housework as a way to maintain some control over the traditionally women's sphere or whether they do large amounts of housework because their at-home husband is not doing it. A third limitation concerns the inability to statistically control for two potentially important variables in our models: 1) outsourcing of housework/caring services and 2) at-home parents' spouses' daily work hours. Although limited current research suggests outsourcing housework or child care makes little difference in time use estimates , the influence of outsourcing on unpaid workloads still requires further investigation. In addition, patterns in our results clearly show that at-home parents' time in domestic work often depends on whether breadwinner parents are working or not. This means some of the differences we identify among at-home parents could be due to differences in their spouses' daily work hours. Unfortunately, we do not have this information in our data but we hope future research can include it. Even with these limitations, this study makes valuable contributions to the scientific literature about the ways in which time availability, earnings-based bargaining, and gender shape time in domestic work. Our comparisons of parents in couples at the extremes-those with one non-working parent and one full-time employed parent-point to the importance of distinguishing among gender-normative tasks and accounting for differences in domestic engagement on work and non-work days for mothers and fathers. Our comparisons also provide a basis for assessing the significance of growing numbers of parents in work-family roles that are not gender-normative. The patterns we find do indicate a possibility for disruption of some gendered domestic behaviors among individuals in gender-atypical arrangements. As the numbers of men and women in these arrangements grow, future research could focus on the potential for exposure to gender-atypical experiences to promote a broader conception of work and family responsibilities that is necessary for greater equality. Maryland, R01HD053654; University of Minnesota, Z195701), both funded through grants from the Eunice Kennedy Shriver National Institute for Child Health and Human Development . ---

We analyze American Time Use Survey (ATUS) data to examine patterns in domestic work among at-home and breadwinner parents to further gauge how time availability, relative earnings, and gender shape time use in couples with extreme differences in earnings and work hours. We find that involvement in female-typed housework is an important driver of overall housework time. It is counter-normative housework behavior by at-home fathers that shapes conclusions about how time availability, relative resources, and gender influence parents' housework. While time availability appears to shape child care in comparable ways across parents, mothers are more engaged in child care than similarly-situated fathers. Overall, our comparisons point to the importance of distinguishing among gender-normative housework tasks and accounting for differences in engagement on work and non-work days. Our results also provide a basis for assessing the social significance of growing numbers of parents in work-family roles that are not gender-normative.

Introduction The Sustainable Development Goals of the UN adopted in 2015 focus on major problems like poverty, education, gender equality, and climate change. To address prevailing global issues and challenges, the UN adopted 17 goals with 164 indicators which should be achieved by the year 2030. India is also committed to these global goals to promote the social and economic condition of its people [1]. The SDGs are a policy framework in India that is being implemented in the form of national policies, programs, and schemes by the NITI Aayog. The goals can be achieved by the country through the cooperation and coordination of all the stakeholders. Youth as one of the stakeholders carries crucial responsibilities to attain the SDGs. Youth are defined as persons between the age of 15 to 24 according to the UN. However, youth are defined in India, as persons between the age of 15 to 29 years [2]. Biologically, youth is a transition period from childhood to adulthood [3] (where the adolescent undergoes social, physical, intellectual, and psychological growth. Young people are the innovators, creators, builders, and leaders of the future. Youths are a major force for sustainable development and key agents for social change, economic growth, and technological innovation. However, without access to food, health, education, sports, and employment, youth potential can't be achieved. India is considered the youngest and second largest country in the world with 371.4 million young 1 3 people by 2021 [4]. However, India as a fast-growing economy is not utilizing the full potential of the youth group as an added advantage for the growth of the country. For youth, to fulfill their basic needs; education and employment are fundamental and should be provided to them without discrimination [5]. Consonantly, Goals 4 and 8 are also insisting on the importance of quality education and decent work for all. Youth plays a crucial role in the development of the nation. They are considered a valuable segment of the population. Therefore, the participation of youth in SDGs is basic to access education and employment for their livelihood. --- Participation of youth in education and employment of youth in India India as the youngest country with the highest youth population of 34.8% has established various policies and programs for the Youth as they face various problems and multiple discriminations [6]. The lack of access to resources and opportunities affects the comprehensive development of the youth [7]. Furthermore, due to a lack of awareness among the youth resist their active participation in government programs and schemes. Illiteracy and unemployment are the two major issues for youth in India that combat them to fulfill their basic need and attain their development needs [8]. Education is considered as one of the important factors for human growth and development. It also accented as one of the Fundamental rights according to the provision enshrined in Article-21 A of the Constitution of India. Nevertheless, there are various forms of discrimination in the functional system of society, such as caste, gender, and social status. Due to this inequality, many important factors for human growth, such as education, health, and employment, haven't been equally applied to all. Further, since today's youth transitions are complicated, it is a herculean challenge for the younger generation to find employment in the present Indian labor market. As per the periodic labor force survey, during the April-June quarter of 2021, 25.5% was the youth unemployment rate in urban India, which rose around 3% compared to the January-March quarter of 2021 [9]. According to Census 2011, more than two-thirds of the total population in India is located in rural areas. In 2022, the unemployment rate in rural areas rose to 8.3% from 6.62% [10]. It was observed that the unemployment rate is higher in rural areas based on the labor force participation of the youth. The labor force participation rate of India manifested that 38.1% of rural youth were employed whereas, in urban areas, it was 38.7% in 2019 [11]. In education, compared to the total population of youth , 37.4 million youth had been enrolled in higher education in Indian educational institutions [12]. It is furthermore concerning that the unemployment rate of educated youth in India is 13% [13]. The reasons like lack of inculcation of skills, high competition due to high population, prejudices and cultural restrictions over career choices, and the unequal accessibility of resources are the causes for unemployment among the educated youth in India. Mere education degrees without inculcation of skills are not helping the youth to get employment [14]. Therefore, creating education and employment opportunities for the youth must be the top priority of both the state and union governments. Consequences of the high population lead to complexities of problems and demand for adjoining administrative inferences. Furthermore, the persistence of social and economic inequality in terms of access to basic services such as access to education, access to basic health care services, access to basic amenities , access to credit and financial facilities, and access to justice across states is another major problem in India [15]. The social stratification in India based on caste, class, and gender is also creating hurdles for marginalized youth to participate in education and employment as the resources are distributed to the people with power instead of people with need. --- Social stratification in India: negation of education and employment The term 'people with power' in the Indian context indicates the people from the upper caste. Caste is a social division of people originating from the Hindu religion. The term 'scheduled caste' indicates a group of people who were previously considered 'untouchables' as they are placed in the very lowest position in the Hindu social structure. They are being isolated from society and denied to participate in common social, economic, political, and cultural activities [16]. Especially, the marginalized environment and structural barriers deprive social interactions [17]. Therefore, the SC youth in India are facing intersectionality of discrimination to even fulfill their basic needs; because their fundamental rights and necessities have been violated by oppressive actions. The primary action taken by the Indian government to combat caste discrimination is political changes built on the principles of the Constitution. Schemes and policies are hence the 'rights' granted to the SC. --- SC youth participation in education and employment In India, the Scheduled Castes are forced by socio-economic constraints to remain at the bottom of the social order, and as a result, they deal with social exclusion daily. Despite completing higher education, the SC youth continue to be unemployed or work as casual or day labourers as a consequence of their historical marginalization [18]. Under Article 45 of the Constitution of India, education is free and compulsory for all children below the age of 14 years. Under Article 46, education is to be promoted for the educational and economic interest of the Scheduled Castes with special attention to the interests of the Scheduled Classes. However, young people face difficulties in getting scholarships and exemption from paying the tuition fee that they are eligible for. It prevents them from participating in higher education [19]. The caste system in India is socially accepted and deeply rooted and used to marginalize individuals and determine their social and economic standing. It denies the people of lower caste such as the SC to access the public resources and resources available [13]. It is viewed as thehigh percentage of illiteracy among the SC youth even though it is one of the fundamental rights of Indian Citizens [20]. However, the institutions and mechanisms of society still practice this kind of prejudice. Consequently, the SC community is directly impacted by the initiatives created by the current system [21,22]. Particularly marginalized youth such as SC youth are vulnerable in terms of their lack of accessibility to the available resources. The Government of India has special schemes to enable access to opportunities including scholarships for education, financial support, and skill building for setting up enterprises, reservations in jobs, and special courts to address instances of atrocities and violence [23]. However, Narwana et al. [23] argues that despite of provision of affirmative actions like providing scholarships to increase the educational status of SCs, the lack of accessibility of such schemes is due to poor governance and mechanism implemented by the government [23]. So, the gap between the schemes and people should be addressed for impactful implementation of the policies and programs. Based on the National Sample Survey [24] quinquennial survey of employment and unemployment shows that there were about 12% of total youth in India remained illiterate in 2009-10 [24]. Alarmingly, one-third of the total illiterate youth, 123 million, in the world is located in India [25]. Thus, it is inferred that educational levels, literacy skills, and vocational skills among the youth in India seem to be very low. By social groups, Scheduled Castes and Scheduled Tribes respectively account for 16.6% and 8.6% of the total population in India. The unemployment problem of the youth is still another major issue that needs to be addressed. It is estimated that 96.8 percent of all young workers in developing countries are in the informal economy [26]. During 2018-2019 unemployment rate for SC youth in the 15-29 years age bracket moderated but remained high at 17.3 percent, as against 20.6 percent a year ago [27]. In India, the SDGs have been implemented through various programs, schemes, and policies. But, the active participation of the youth in the schemes and programs determines their participation in the SDGs. Thus, the paper focuses on education and employment as both factors are crucial in the transition period of youth contributing to their intellectual and independent development. Therefore, the authors attempted the study to examine whether SC youth use the programs and policies. It was observed that the low level of participation of youth from SC in education and work indicates that they are less likely to participate in government programs and policies that support Sustainable Development Goals 4 and 8 respectively. --- Theoretical framework Youth is an integral part of society and their participation in social development is viewed as critical. However, youth in India face many hurdles to their participation in development programs due to social, economic, political, and cultural factors. Particularly, SC youth participation is found less in the government schemes and programs that are designed specifically for them due to a lack of access to opportunities and resources. The lack of awareness leads to a lack of participation of SC youth and that can be set right through the institutional mechanisms and inclusive approaches. The concept of institutionalism indicates that government organizations as institutions that have the legitimacy to enforce, determine, and implement schemes, policies, and programs for the people of the nation. However, paradoxically the gaps in the institutional mechanism as it does not provide the specific framework for the effective implementation of the schemes and programs and for creating an impact on the target population. It is the role of the government institution to reach out to the target population through decentralized governance particularly anything that concerns the marginalized i.e. SC youth. Figure 1 depicts the conceptual framework for enhancing youth participation in achieving the SDGs. Thus the pragmatic role of government institutions is essential to ensure the participation of SC youth. It is also a fact that the systems associated with the SC youth also affect their level of awareness and participation in government schemes. Emile Durkheim viewed society complex system of interrelated and interdependent parts working together. He emphasized that values, customs, and religious beliefs are the dictators of society [28]. Caste as an ascribed type of socially accepted status determines the development of individuals based on the caste they belong instead of their capacity. It is a traditional and religious notion that is deep-rooted in the minds of the people. The caste as the authoritative power marginalizes the individuals and denies them to access resources. To eliminate such kind of discrimination imposed over people, schemes, and policies are being established by the State and Central Governments. But due to Fig. 1 Conceptual framework for enhancing youth participation in achieving the SDGs lack of awareness of schemes decreases the participation of SC youth in the schemes, particularly those schemes that are specifically designed for them. --- Problem statement The Agenda 2030 views youth as critical change agents in the SDGs and stresses the importance of strengthening the partnership between youth and other stakeholders. There are 17 Sustainable Goals and of them, Goal 4 and Goal 8 are more significant in the sense it is directly related to the social and economic development of a country. The 2011 Census reveals that the population of Scheduled Caste is 20% in Tamil Nadu. Although numerous Central Government and State sponsored schemes and programs have been implemented in the State, however, the participation of SC in Tamil Nadu is significantly less in certain districts due to poverty, and lack of access to information are major obstacles, the problems of SC youth in Tamil Nadu are similar to those across the country. That's the reason the National Institution for Transforming India; Commission identified Ramanathapuram and Viruthunagar as Aspirational Districts of Tamil Nadu. Furthermore, the State Government of Tamil Nadu has identified Dharmapuri district to be given due consideration owing to its backwardness in social development. Besides the densely SC-populated districts such as Chennai, Thiruvallur, Kancheepuram and Vilupuram districts have also been taken considered for the study. The primary objective of the study is to identify the factors that hinder the participation of SC youth in the Central Government and state-sponsored schemes and programs that are in line with the SDGs. --- Materials and methods The data manifested in this paper is retrieved from the published research project, titled "Social Reality of Scheduled Caste Youth in Tamil Nadu Concerning Sustainable Development Goals". For the study, the descriptive research design was adopted to describe the status and participation of SC youth in SDG 4 and 8. A structured interview schedule was used to collect data from the Scheduled Caste youth from seven districts of Tamil Nadu, Viz, Ramanathapuram, Dharmapuri, Viruthunagar, Villupuram, Tiruvallur, Kancheepuram, and Chennai. A total, of 90 respondents participated in the study and the multi-stage sampling technique was used to select the respondents. Informed consent was obtained from all the respondents. Ethical clearance was obtained from the respective institute. Besides the empirical data, the paper also congregates secondary data to support the argument of the researchers and to expound the essence of the primary data. Content analysis of secondary data was administered to contemplate and strengthen the findings of the study. The secondary data were obtained from the sources viz., the Indian Labor Organization, Ministry of Statistics and Program Implementation of India, All India Survey on Higher Education, Periodic Labor Force Survey of India, and other related Government publications, journals, articles, and newspapers were being used to understand the participation of Scheduled caste youth in education and employment. --- Results and analysis a. Socio-economic profile of the respondents It is observed from Table 1 that male respondents are more than female respondents, which indicates less participation of female youth in the Youth club activities due to gender disparity in family and community. It is revealed from the study that most of the respondents hail from rural areas and it has to be noted that SC communities live in rural areas live separately and are neglected whereas all caste communities coexist in urban and semi-urban areas. While, 35.5% of respondents engaged in employment paid every month, and a sizeable are daily wage earners whereas 6.8% are paid every week. However, 37.7% of respondents are under the category of students or unemployed. This indicates the lower socialeconomic status of the SC youth in the selected districts of Tamil Nadu. b. Awareness participation of SC youth in government schemes and programmes Table 2 depicts the results of the Mann-Whitney U Test and it revealed that there is no significant difference in the Awareness level between the Aspirational districts and other districts in terms of Goal 4 since the hypothesis of the above sample test is rejected as the p-value is greater than the significant value. On the other hand, it has to be noted that there is a significant difference in the level of awareness among the respondents between the Aspirational districts and other districts concerning Goal 8. The Aspirational districts have scored higher than the other districts which reveals that the awareness level in the aspirational districts is higher than the other districts in Goal 8. Table 3 shows the results of Kruskal-Wallis Test for the participation of Schemes and programmes by the respondents between the Aspirational Districts and Other districts. Since the p-value of the test is greater than the significant value, the hypothesis of the above sample test is rejected. Thus, it indicates that there is a difference in the level of participation among the respondents across the seven districts. Particularly, Ramanathapuram , Dharmapuri , and Viruthunagar have scored higher than the other districts. It has to be noted that Chennai scored less which indicates the low level of participation of the respondents in the State and Central government schemes. --- c. Sustainable development goal number 4-quality education In India, the overall gross enrollment ratio in higher education is 27.10% between the age group of 18-23 years [29]. The overall male enrollment is 26.90% in which the enrollment of SC males is 22.8%. Similarly, the female enrollment ratio level is 27.3% whereas for the SC female, it is 24.1%. The Enrollment status of Tamil Nadu youth and SC youth has been depicted in Figs. 1,2. It shows the rise in education enrollment between 2015 and 2019. The rate of enrolment decreases between 2019 and 2020 year. Many empirical studies stated the low enrolment rate between 2019 and 2020 was due to COVID-19. Education is the biggest sector adversely affected by the Pandemic [30]. Figures 2,3 show a gradual increase in enrolment during the years 2015 to 2018 and started gradual decrease in the following years 2019 and 2021. The reservation system in India is a right for inclusive participation among all social groups in which the reservation for SC is 15% [31]. Both the empirical data and the secondary data analyzed the gradual decrease in participation of the SC population in education. To promote inclusive education, the Indian government as well as the Tamil Nadu government offer various scholarships and schemes. The post-matric scholar- ships, tuition fee exemptions, educational incentives, and free laptops [32] cycle schemes are provided for the SC youth to promote their educational status by the Government of Tamil Nadu [33]. According to the Sustainable Development Goals Report , SDG-4 foresees to 'ensure inclusive and equitable quality education and promote lifelong learning opportunities for all [34]. One of the targets of Goal 4 is by 2030, countries substantially increase the number of youth and adults who have relevant skills, including technical and vocational skills, for employment, decent jobs, and entrepreneurship. Similarly, countries target by 2030 to ensure that all youth and a substantial proportion of adults, both men and women, achieve literacy and numeracy . The Table 4 shows the educational qualification of the respondents and it indicates that the maximum number of SC youth had access to higher education . But on the contrary, it is a serious concern that 24.40% and 10.00% have not even completed their higher secondary education. Similarly, the interfered secondary data also reveals the decrease in educational participation of SC from 2018 to 2020 . Since the p-value of the test is lesser than the significant value , the null hypothesis of the sample test is rejected and the awareness level about goal number 4 is not equal across the 7 districts as shown in Table 5 above. Ramanathapuram district has more awareness about various educational schemes of state and central government comes under Goal no-4 . Viruthunagar 1 an Aspirational district, holds the last with a 29.54 median rank with low awareness about educational schemes and policies. This suggests that the district needs to develop its educational system. --- d. Sustainable development goal number 8-decent work Goal 8 guides countries to promote inclusive and sustainable economic growth, employment, and decent work for all [35]. One of the targets of Goal 8 is to achieve full and productive employment and decent work for all women and men, including for young people and persons with disabilities, and equal pay for work of equal value by 2030 . The other target focusing on youth is to substantially reduce the proportion of youth not in employment, education, or training by 2020. In addition, by 2020, countries to develop and operationalize a global strategy for youth employment and implement the Global Jobs Pact of the International Labor Organization. The lower education levels of SCs make most of the population unskilled and the majority of the SC population are working in the informal sectors [36]. The discrimination in the labor market that exists in both the formal and informal sectors shows that employment opportunities have not been provided solely based on education qualification but consider the social category of the individual. The youth unemployment rate has been increasing over the years. The SC youth is the one who has been deprived of opportunities and resources and becoming vulnerable and struggling to establish a basic livelihood. SC has the highest unemployment rate in India since the 1990s [37]. Table 6 shows the employment status of youth in correlation with their age. A maximum number of respondents who participated in the study were employed. However, it was also investigated that most of the SC youth who participated were underemployed. status of women and men from SC with Non-SC social categories. Both the pictures show that compared to other caste groups, the SC males and females are majorly involved in casual work which does not have any security or employment guarantee. --- Hypothesis There is no significant difference in awareness level between Aspirational districts and Other districts concerning SDG.8. The hypothesis of the above sample test is rejected since the p-value of the test is greater than the significant value. Table 7 shows that the Ramanathapuram district has high awareness about schemes related to decent work and Tiruvallur ranks low among the seven districts. --- Discussion Although the study reveals that 63.40% of SC youth have reached the higher education level , it has to be noted that a sizeable population of the SC youth did not complete their higher secondary. This finding corroborates with the secondary data obtained from AISHE [29] as it indicates that there was a decline in the participation of SC youth in higher education from 2018 to 2020. It has to be noted that the lack of opportunities and participation prevent the SC youth from accessing appropriate employment based on their education qualification. Similarly, the study reveals that although 42.2% of the SC youth were found employed they remained underemployed. Furthermore, 4.4% of the SC youth were observed unemployed. Thus, it seems that underemployment and unemployment are common among the SC youth in Tamil Nadu. The study findings substantiated with the secondary data obtained from Periodic Labor Force Survey, [38] that the unemployment rate increased from 19.9 to 23.9%. Thus, lack of opportunities and participation resist the SC youth to access appropriate employment based on their education qualification. The Percentage of the workforce of non-SC is high in the area of regulated salary and self-employment compared to the SC population who are majorly involved in casual labor. Their engagement in the unorganized sector and short-term jobs increases their vulnerability to poverty. Hence their participation in the organized sector must be encouraged so that they would be protected with the legislated benefits [39,40]. The Kruskal Walis test revealed there is a significant difference between educational status and awareness of schemes and programs among the respondents across the selected districts. Therefore education plays a crucial role in enhancing the participation of SC youth in the SDGs41 The Kruskal Wallis Test revealed that there is a significant difference between awareness of SC youth across the seven districts and the programs and schemes related to Goal No.4 Quality Education and Goal No.8 Decent Work . Hence the Government of Tamil Nadu must ensure that these goals are achieved by the SC youth through legal enforcement and Context-specific approaches and welfare measures. The participation of SC youth in the schemes and programs between the Aspirational Districts and other districts tested by the Mann-Whitney U test reveals that there is a significant difference at 0.005 level . Thus, it indicates the effective Governance in the Aspirational districts in terms of participation in the schemes and programs of State and Central Governments. Availability of schemes along with the awareness and accessibility of the schemes is important. The lack of awareness among the SC youth about the available schemes and policies and the lack of administrative and organizational resources to provide awareness and educate the SC youth about the schemes and policies are the reasons for the lack of participation of SC youth in the education and employment sectors. Thus, the conceptual framework manifested in the study can be used as an integrative approach that emphasizes the application of National and state youth policy through the integrative functioning of the Government and non-government organizations along with the micro, mezzo, and macro inferences of social work methods to enhance the participation of SC youth in education and employment schemes in line with the Sustainable development goal number four and eight. The accessibility and increased educational and employment participation primarily help the SC youth to fulfill their basic needs and it is also a tool to liberate themselves from the state of marginalization. The ultimate purpose of education should elevate the conscientization among the Scheduled Caste youth about the perpetual persecution faced by them and should give them the power to unleash their tyrannical social structure. Therefore, the achievement of sustainable development goals ultimately promotes equality and justice. --- Implication of the study The article critically examined how Scheduled Caste youth participated in SDGs 4-Quality Educationand 8-Decent Work. Increased engagement of SC in school is a result of several years of ongoing social reforms. The amount of SC youths enrolling in higher education is, however, very small. In terms of employment, underemployment overtakes unemployment as the main concern for young people in the Scheduled Caste. In this study, the difficulties SC youths have in obtaining a quality education and decent employment were studied and mainstreamed. It provides policy and program planners with the ground-level reality they need to develop proactive inclusive and equity policies that will raise the standard of living for SC youth. The study's findings will be very helpful in creating targeted programs and interventions that will improve the involvement of SC youth in the SDGs through government schemes and initiatives. The NYKS needs to take a proactive approach at district levels to ensure the participation and development of SC youth by recognizing their social contexts. --- Data availability The datasets generated during and/or analyzed during the current study are available from the corresponding author upon reasonable request. --- Author contributions S. Lalitha -Wrote the main manuscript, prepared the figures and reviewed the manuscript Avilash Roul -Wrote the main manuscript and reviewed the manuscript N. Karpagam -Wrote the main manuscript, prepared the figures and reviewed the manuscript S. Sona -Wrote the main manuscript, prepared the figures and reviewed the manuscript --- --- Competing interests The authors declare no conflict of interest. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/.

For achieving the targets of the Sustainable Development Goals (SDGs) it is very much called for the meaningful participation of the youth. The young population in India is sizable, diversified, and affected by a wide range of problems. Due to their social status and caste rigidity, youth from Scheduled Castes (SC) are vulnerable. Despite numerous laws and programs, Tamil Nadu's programs for SC youth have a lower-than-average active participation rate. Their transition and social development are negatively impacted by poverty, unemployment, illiteracy, discrimination, and the lack of opportunities. Numerous empirical studies have examined the status of SCs in terms of their involvement in work and education, but none have yet studied their participation in accomplishing the SDGs. This paper examines how SC youth in Tamil Nadu participated in the SDGs. Subsequently, it offers an inclusive strategy to increase SC youth participation in accomplishing the SDGs.

Introduction "I will not follow where the path may lead, but I will go where there is no path and I will leave a trail." -Muriel Strode [Lieberman] 1 Despite the claims made by librarians for school libraries' contribution to development, they seem to attract only token support from teachers and educational administrators in many parts of the world, and often remain, at best, underfunded, inadequately staffed, and little used. This deplorable situation is evident in many wealthy, industrialized countries with otherwise well-developed library and information services, as much as in countries that are generally less well-developed. Among the latter, Iraq provides an example on which this paper has chosen to focus. Iraq was formed from three provinces of the Ottoman Empire when that was dissolved after World War I, and became an independent state in 1932. From the middle of the twentieth century, rapid growth in the state's oil-based income facilitated substantial investment in education. However, heavy investment in education appears to have made little significant difference to the state of the country's school libraries. This paper seeks to shed fresh light on some of the underlying issues to explain why this archetypal situation occurred and has persisted. To that end, it aims to examine the development of the school education system and school libraries in Iraq, taking account of the levels of literacy in the country, the state of its publishing industry, the provision of public libraries for children, the context provided by the national economy, politics and social change, and the role played by the relevant international governmental and nongovernmental agencies . From the available evidence it seeks to explain why Iraq's school libraries have generally remained inert depositories, and discusses some implications for the development of school libraries internationally. --- Early School Libraries in Iraq There is a long history of libraries associated with educational institutions in Iraq, beginning in the edubbas, the schools for cuneiform scribes that began to be established in the second millennium bce, and continued, from the advent of Islam, by the libraries that grew alongside mosques, together with the schools known as kuttabs where students were instructed in memorizing the Qur'an. Writing, arithmetic, and other subjects were also taught in some kuttabs. In the madrasas, which were centers of higher learning that began to be founded in the ninth century ce before printing made books more readily available, the teachers generally knew their own works by heart and sometimes had to dictate the text of a lecture. However, the teachers often sought to check that their students had followed and understood their arguments, while students were permitted to ask questions, discuss what they had learned, and, if they had evidence to support their opinion, to challenge the teachers . Indeed, a teacher's knowledge and ability to answer questions were among the tests of competence . After several hundred years of stagnation, the Ottoman administration finally recognized, in the middle of the nineteenth century, that improve-ments were needed in the education system to supply the literate and numerate staff required for an effective imperial bureaucracy and thus began to establish schools throughout the empire. At least one of these schools, in Samarra in Iraq, was given a library . At the same time, schools were being founded by monastic orders long resident in Iraq, especially the Dominicans, by other Christian and Jewish community groups, and by foreign missionaries. Libraries are known to have been established in some of them; for example, in the "School of High Hope" founded in Basra by missionaries from the American Dutch Reformed Church in 1912 , and in "Baghdad College," a secondary school founded by American Jesuits in 1932. It was in schools such as these that the children of the Iraqi elite would probably have had their first experience of "modern" library service. For example, the library installed in Baghdad College within a few months of its founding, " became the best of its kind in Baghdad. . . . The boys were surprised to learn that they could actually take home to read whatever book they wanted, free of charge" . Throughout the school's existence the library was managed by one or more Jesuit teacher-librarians, although only one of them ever held a degree in library science . Educational administrators and teachers from other schools regularly visited the college, including its library, to find ideas they could use, but this seems to have made little impact on provision elsewhere. In the state schools, in 1944 the Ministry of Education's budget for all its school libraries was only 6,000 Iraqi dinars , compared with ID100,000 for textbooks. Unsurprisingly, in the late 1940s, school libraries in Iraq were still small and little used; only the old, established schools might have as many as a thousand books . --- State Education in Iraq in the Early Twentieth Century The embryonic education system established by the Ottomans in Iraq was said to have been trashed during the Mesopotamia campaign in World War I, allegedly by Turkish troops as they retreated from the advancing British army , although the attribution of responsibility may be open to interpretation. Many of the troops in the Ottoman army were Arabs, and the schools had been unpopular with the civilian population because teaching was in Turkish rather than Arabic. When the state education system began to be rebuilt in the former Ottoman provinces in Mesopotamia that were gradually occupied and administered by the British beginning in 1914, Arabic was introduced as the principal language of instruction. Teachers and books were in short supply. Books had to be imported from Egypt until the local publishing industry was able to meet demand, which included textbooks in Kurdish for schools in the north. In 1919 the British authorities issued a standard syllabus for the state schools, which repeatedly emphasized that students must demonstrate that they understood the meaning of what they had read . Under a Mandate granted by the League of Nations in 1921, the British authorities were required to supervise the development of the government system in the newly designated state of Iraq. By 1923, in keeping with the aims of the Mandate and to reduce the costs of its administration, the British had transferred responsibility for the Ministry of Education's policy decisions and operational management entirely to Iraqis . Sati Al-Husri, the first Iraqi director general of education, apparently favored independent learning methods , but seems to have given little encouragement to developing new approaches to pedagogy or providing the necessary learning resources. Teaching methods in primary and secondary schools were based heavily on memorization of the contents of textbooks and the teachers' presentations. School teachers were trained in the second of the two three-year stages of secondary education and could only function in the same way as their predecessors. The country was poor and its development had to be funded from its own resources because it was not until 1929 that the British Parliament first authorized any expenditure on development assistance for its colonies and protectorates. Nonetheless, during the mandate some three-hundred primary and fifteen secondary schools were opened. A Teacher Training College was established in the 1920s, but the growth of education created a shortage of books in the schools, and because of this the college felt obliged to provide teachers with enough knowledge to last them for the duration of their career. This reinforced the belief that teaching was a mechanical process . Although the teacher-training system did produce some teachers whose approach to their students was said to be more engaging than that of the imams in the kuttabs , concerns about the quality of teaching and learning and the limited use of the state's school libraries continued to be expressed by British advisers to the ministry, who commented in 1929 that "every school has a library of reference books and, in the secondary and higher schools, these libraries are provided in addition with modern Arabic books and Arabic periodicals. But Arabic literature is an unexplored country to the students, and also, it is to be feared, to many of the teachers" . In 1932 a small group of American professors was invited to review the country's education system. The group was led by Paul Monroe, director of the International Institute of Teachers College, Columbia University, where a number of the Iraqi Ministry of Education's senior officials had studied. This Educational Inquiry Commission was particularly forthright on the need for school libraries: Several subsidiary aspects of secondary education need emphasis. There is a great need for increased library facilities. Such library matter should include supplementary reading matter on all subjects, a variety of textbooks in the various subjects both in English and Arabic, and general literary material. At several points in this report, we have commented on the futility of teaching people to read when there is nothing to read. We believe that the introduction of libraries into secondary schools would do much to remedy this in the communities where they are established. These concerns seem to have been ignored, perhaps because of political struggles within the ministry and government . During the period of Hashemite rule , the government of the kingdom generally proved ill-equipped to govern and lacked stability, with the membership of the cabinet of ministers changing frequently. Compulsory education was introduced in 1940, offering six years of schooling, but only wherever the facilities were available. A semi-independent development board controlled the expenditure of most of the state's oil income, from which it supported inter alia the construction of 100-150 new schools each year. Enrollments expanded rapidly but still accounted for only a third of the relevant age group in a growing child population and stretched the country's ability to meet the demand for teachers. Accordingly, the government began to recruit Egyptian and Palestinian teachers, many of whom, according to British academics then working in the country, preferring an authoritarian pedagogy that discouraged students from asking questions . --- The Evolution of International Interest in School Library Development The International Federation of Library Associations was established in 1927-the same year that an intergovernmental body engaged with the field for the first time. A Comité d'Experts Bibliothécaires was asked to identify the problems in the library field by the Subcommittee for Science and Bibliography, which had been established by the League of Nations's Commission on Intellectual Cooperation . Discussions in the early 1930s of the responses to a survey of professional education that had been suggested by the comité and carried out for the commission by the International Institute of Intellectual Cooperation pointed among other things to the need for school librarians to have a good understanding of teaching methods . The International Bureau of Education , founded in 1925 as a private body, became an intergovernmental agency in 1929. During its first few years the publications of the bureau discussed children's literature and the organization and use of school libraries ). However, perhaps because of the state of the global economy and partly because IIIC and IBE could only try to influence matters that were controlled by their member states, and with little funding to support independent activities, no action had been taken on either organization's studies before war intervened. --- UNESCO and the Arab World The UN Educational, Scientific and Cultural Organization's involvement in the Arab world began, in the aftermath of the Arab-Israeli conflict in 1948, in the provision of educational facilities for Palestinian refugees. The work was taken over by the United Nations Relief and Welfare Agency in 1950 . By the late 1980s almost 100 percent of the UNRWA schools for Palestinians had a library and a teacher-librarian . UNESCO's first involvement with school libraries in the Arab world began following the establishment, in December 1952, of the Arab States Fundamental Education Training and Production Centre , based in Egypt. This provided a twenty-one-month program to train fieldworkers to support rural welfare and community-development projects in which library provision was seen as an essential corollary of literacy development. By the end of 1958 ASFEC had established projects, including small public libraries in fourteen or more villages in its vicinity. Neighboring schools were also encouraged to permit public access to their collections of books; such collections were given to selected secondary schools, and training was provided for nominated teacher-librarians . To support a training program in librarianship for interested trainees from projects in other Arab states, a manual in Arabic on the organization of small public and school libraries was produced . When UNESCO was created after World War II, the information available on libraries in the Arab world was so limited that it was difficult for the organization to make any plans for their development . It also struggled to recognize the Arab world as an entity, initially inviting the Arabic-speaking member states to nominate participants in activities intended either for states in the African continent or for those east of the Suez Canal. However, UNESCO was pointedly reminded about the linguistic and cultural differences in the member states in the different regions of Africa by the participants in its "Seminar on Public Libraries in Africa" in 1953 . Eventually this led to UNESCO organizing its first international seminar for librarians from all Arabic-speaking states, which took place in Beirut in 1959. There, the need for school libraries to be developed was explained as a firm foundation on which to build a wider library system and status for librarians. The participants in the Beirut meeting made detailed comments and recommendations about the role of school libraries and the training of teacher librarians, but these were largely omitted from the published final summary report sent to member states, probably because it was common practice for UNESCO headquarters to edit reports to reduce the likelihood of requests for assistance that stood little chance of being approved because they were not part of UNESCO's agreed aims ). The initial agenda of UNESCO's Department of Libraries-heavily influenced by its legacy from the League of Nations' activities and the intervention of the American Library Association-paid no attention to school libraries, although the department was subsequently continually reminded of the need to support school library development by delegates to the international seminars it organized. It was UNESCO experts working in the education field in various countries who first acknowledged that acquiring the habit of reading and the ability to use books for enjoyment and information were likely to be of lasting benefit. These experts helped to plan and organize school libraries and train teacher-librarians, notably as part of UNESCO's "Major Project for the Extension of Primary Education in Latin America," implemented between 1957 and 1965, which called for the establishment of pilot primary school libraries and for assistance in the improvement of existing school library services. This seems to have finally prompted UNESCO's libraries department to include the promotion of school libraries among the priority objectives of its development program, and to commission its first publication specifically about school libraries . However, in the 1960s, because the UN had encouraged its agencies to focus on economic development, UNESCO placed more emphasis on support for special libraries. Nonetheless, it has subsequently facilitated school library development in Jordan and a few other countries . --- International Support for the Development of Literacy Literacy development attracts support from bodies like the World Bank and the Organization for Economic Cooperation and Development, as well as most bilateral government development agencies, and has been a focus of UNESCO activities since its inception. It remains a major activity for UNESCO's education sector, which supports the promotion of literate environments as a foundation for cohesive societies and sustainable development. UNESCO convened its first Arab regional conference on the planning and organizing of literacy programs in Cairo in 1964. Although no librarian was present, delegates supported the use of teaching methods that stimulated learners' interest in the subject, showed an appreciation of the need for new literates to be provided with suitable reading materials, and encouraged governments to provide reading rooms . However, seemingly no librarians were invited to participate in another UNESCO meeting in 1968 regarding literacy materials in the Arab world. The report on the latter meeting shows no awareness of the potential role of libraries as an agency for making supportive reading material available . The IFLA began to engage with literacy development in 1989, organizing a preconference on illiteracy and public libraries with support from UNESCO's Programme General d'Information . In 1994 a new IFLA core program for literacy and reading promotion was proposed, but rejected on financial and organizational grounds. Instead, a working group was created to study the feasibility of a major IFLA initiative to support literacy program in libraries. The IFLA Section on Literacy and Reading was established in 1995 as the Round Table on Reading Research, became the Section on Reading in 1996, and adopted its present name in 2007. It now provides a focal point for the promotion of reading and literacy in libraries, and the integration of reading research and reading-development activities into library services. It claims to work in cooperation with a number of other international bodies, including the International Literacy Association and the International Board on Books for Young People . The ILA, formerly known as the International Reading Association , was founded in 1955-1956 and changed its name in 2015 . It does not enjoy the same level of formal recognition by UNESCO as IFLA, having been granted only consultative status with the Education and Culture sectors. However, it has some seventy-thousand members in over a hundred countries, through whom it advocates for literacy development, both preschool and in the school curriculum, and promotes the contribution of independent reading to learning development. It has produced a position statement supporting the development of both classroom and school libraries , but its guidelines for the performance standards that might be expected of professionals working in the field do not acknowledge the role of the teacher-librarian nor the school librarian , which casts some doubt on the IFLA section's claim of cooperation between the two associations. --- Literacy and Education in Iraq Little improvement in the overall literacy rate in Iraq had been achieved by the middle of the twentieth century. In 1957 only 11 percent of the total population of Iraq was literate . Recognition of the connection between education and national development began to lead to a belated appreciation in Iraq and other developing countries of the need for investment in the development of their human capital . Successive Iraqi governments recognized the need to improve literacy rates, and that one of the first tasks of schools is to develop basic literacy in their students. When Iraq hosted the 1966 meeting in ALECSO's "Alexandria" series of conferences on literacy, it claimed that its literacy rate among children of school age had reached around 76 percent by 1965. While UNESCO's support for literacy development in education at all levels was steadfast, it consistently failed to identify a role that library services could play and to actively encourage support for them. For example, discussions at the Third Regional Conference of Ministers of Education and Ministers responsible for economic planning in the Arab states in 1970 reflected the continuing emphasis on the use of textbooks and made no mention of independent reading or libraries . Eventually, an appreciation of libraries' role in supporting literacy development did establish itself in official thinking, but was confined to public libraries, perhaps understandably in the changing circumstances . As the government in Iraq and other Arab states moved closer toward achieving comprehensive availability of school education, the attention of literacy developers turned to the ongoing problem of adult illiteracy. --- Public Children's Libraries in Iraq Public children's libraries can provide an alternative or supplementary source of reading material for young people when school library provision is limited. In Iraq the first public libraries were established during the British Mandate, and then by the Iraqi government. As a result, public libraries were to be found in major cities in the country in the 1930s , earlier than in most other Arab countries. After 1948 the public library provision was extended across the entire country, with the establishment of a central library and branches in each of the Liwas . Initially, most were small; they were also little used partly because of the low level of literacy, but also perhaps because the collections were of limited interest, being dependent on the output of the Arabic-language publishing industry. This particularly hindered provision for children. The first reported development aimed at children took place only in 1958 when an annex was added to the Mosul Public Library to provide space for a children's room, among other things . Des Raj Kalia, an Indian librarian who worked in Iraq as a consultant for UNESCO on several occasions, claimed to have subsequently persuaded the authorities in many Liwas to open children's libraries . Perhaps reflecting the need to reinforce the literacy of a growing population of young people, a specialized children's library was founded in Baghdad in the mid-1960s, built with the assistance of the Gulbenkian Foundation as part of a center for young people between ages 5-14 . The then prime minister, who had been a school teacher, was said to have been personally interested in the project, and several international agencies are reported to have donated quantities of books. Otherwise, the international agencies seem to have made little effort in this direction, which appears at odds with their aim to promote the use of the English language and win the support of future influential citizens. In the late 1950s the British Council librarian in Baghdad attempted to encourage reading by children, but had to rely upon donated books to provide a collection suitable for their use. In the early 1970s, U.S. Information Service libraries ceased to provide children's books . --- Publishing in Iraq Development of both school libraries and public libraries for children was hindered by the limited output of the Arabic-language publishing industry. In a comment regrettably buried in a section of its report devoted to textbooks, the Monroe Commission recommended, "Much supplementary material needs to be prepared. No great purpose is served in teaching children to read, if they do not read. If there is no material of interest available, the skill in reading is soon lost. . . . The entire reading textbook material . . . is far too meager material with which to train a child to read" . These worthy aims failed to reflect the state of the Iraqi publishing industry, whose growth was inhibited by the small number of people who were both literate and sufficiently affluent to purchase books. Between 1920 and 1945 only 1,904 titles in toto were published in Iraq . In the 1930s the Ministry of Education became an important publisher through its employment of factual and creative writers for its textbooks and other publications . However, the presentation remained largely factual, with little to stimulate interest or thinking; the physical format was also poor and unappealing . During the 1940s the ministry's budget continued to include funds for buying books for school libraries, but these were dwarfed by its expenditure on printing the millions of copies of textbooks that were distributed to schools. In the period immediately after World War II, the local publishing industry was becoming more established, but its output remained limited, totaling only 3,204 titles between 1946 and 1957 . Printing presses in Iraq produced mainly government-sponsored publications; other books were printed only at the author's expense . In the early 1950s there was no local publishing for children other than the still unattractive textbooks . The first of many attempts to improve the regional book trade to offset the low national production of books in each of the Arab states was made at a conference organized by the League of Arab States in Damascus in 1957, but even today these efforts have had only a limited impact because of continuing poor bibliographic services and import restrictions imposed for political or fiscal reasons. Even so, the number of children's books available throughout the Arab world is small. Tunisia, for example, today publishes only 150-200 children's books annually, and prices remain high in relation to incomes . Foreign aid agencies made token gestures toward improving the supply of books for young people. In 1955-1956 USIS provided two-hundred secondary school libraries with American books, translated into Arabic. The collections, each approximately 120 volumes, were presented in "a self-standing, modernistic book-case" . In the 1960s, Soviet foreign-language publishing included a small number of books in Arabic for children: those for younger children usually told a simple moral tale, while those for older ones carried a propaganda message . The American books provided by USIS would probably not have escaped similar descriptions. --- Education in Iraq in the Second Half of the Twentieth Century According to the Iraqi Ministry of Education, by 1964-1965, enrollments increased in primary schools by 300 percent, and in secondary schools by 400 percent . By the late 1960s, Iraq had come close to achieving the necessary complement of trained school teachers . Nonetheless, a shortage of school buildings resulted in cohorts of children sharing school premises , no doubt placing a premium on the availability of space for activities other than teaching. A later commentator remarked: "The emphasis on quantitative expansion of education was surely a major success for the republican regime . . . but has obstructed the emphasis on the quality of that education" . Compulsory primary education for all children from age 6 up to age 12 was reconfirmed in 1976 as a goal to be implemented during 1978-1979; however, progress was slow, and it was not expected to be achieved until 1980-1981). Secondary education for three or six years remained optional, and only about 25 percent of primary school students continued to the secondary level . However, sometime before 1970, in order to improve the quality of teacher training, the training of primary teachers as part of the second phase of secondary education had been discontinued . The war with Iran that dragged on through most of the 1980s had serious consequences for Iraq's economy, social infrastructure, and human resources. The country started the 1980s better equipped than most other Arab countries, but then government expenditure on education began to decline and school attendance was affected by shortages of staff, especially at the secondary level. A study of teacher training in Iraq, undertaken around the time of the end of the war, identified major limitations: first, in its organization, content, and structure; and second, in the use and under-standing of the possibilities of educational media . This was rendered irrelevant following the UN's embargo on exports to Iraq following its invasion of Kuwait in 1990. The sanctions caused further shortages of educational materials and equipment. Enrollment rates declined, children dropped out because of their families' economic circumstances, and literacy levels dropped. --- School Libraries in Iraq in the Second Half of the Twentieth Century It was reported that at the end of the 1950s all schools in Iraq had small libraries . However, there was not a properly run school library in all of Iraq, according to Kalia . According to an assistant librarian at Baghdad College, there was no library room in state primary schools. Books were kept in cupboards in the head teachers' rooms. Schools were not allocated funds for acquisitions. The "teacher-librarians" had no special training, and they were granted no relief from teaching for their extra duties as librarians. Secondary schools were a little better; they usually had a room with a few places for reading and set times for the circulation of books . Consultants employed by UNESCO continually attempted to foster interest in the role of school libraries. For example, a U.S. educational consultant proposed that the Ministry of Education establish a school libraries advisory committee . A British consultant, working for UNESCO on a general program of library development, conducted two seminars for teacher librarians, supporting it by preparing a textbook of library practice for schools that was later adopted and published by the ministry. He also advocated improvements in the staff in school libraries and in the Ministry ). The Iraqi government had, however, clearly been persuaded of the need for action, but this seems to have not been grasped or reported to Paris by the UNESCO resident in Iraq, and UNESCO probably did little to help when in 1958 it rejected a request by the Iraqi authorities for a fellowship to study school librarianship . The ministry was reorganized in 1958, creating a new post of director of school and public libraries. Moreover, the ministry was sufficiently interested in the state of its school libraries that it issued regulations in the same year, outlining precisely how it expected them to operate and the role of each school's library committee. All this was to be monitored by a team of specialists. It also prescribed that, in those schools that had a library room, the timetable should be arranged to ensure that all students spent an hour each week in the library; students' families were expected to make a small "voluntary" payment for use of the library. The manual for teacher-librarians, based on the one written by Bonny in 1959, was distributed to all schools, but the teacher-librarians could not make effective use of it . some issues facing many school libraries/johnson 229 Kalia claimed to have persuaded the Ministry of Education to fund two model school libraries in Baghdad, and to centralize both the acquisitions and processing of school library books for the entire country. Kent and Haidar reported that on average, each school library had received 950 books during an eighteen-month period. In a draft report on the first of several missions to Iraq, Srivastava reported that in 1965, official statistics claimed that there were 3,204 primary school libraries, with 733,000 volumes serving 253,000 students; and 395 secondary school libraries, with 591,000 volumes serving 111,000 students. 2 It seems likely, however, that the "library" collections were little more than multiple copies of textbooks. The scale of library development that appeared to gather pace in Iraq during the 1960s was principally manifested in new premises-token gestures toward modernization that disguised the lack of appreciation of what was needed to develop effective services, stemming from a severe shortage of professionally qualified librarians to plan and manage operations. Throughout the decade, however, a number of Iraqis began to be identified as contemporary or future leaders in the professional development of librarianship. One who can be singled out for his efforts was Nihad Abdul Majid , the first director of school and public libraries, for whom both UNESCO and the British Council provided assistance and motivation. He clearly made some substantial efforts, not only in improving the quality of school libraries and raising their visibility by his 1963 book on school librarianship , but also in gaining support for formal education and training for the school librarians for whom his directorate was responsible. A U.S. consultant, although visiting Iraq to review the potential involvement of the Ford Foundation in Baghdad University's libraries, noted: "The Minister of Education is especially interested in doing something about school libraries. I have suggested . . . the possibility of having enough courses offered in the Higher Teachers College to produce a supply of teacher librarians" . At the end of the decade, libraries in secondary schools, although better than those in primary schools, were still inadequate according to Iraqi educationalists . However, substantial steps were taken during the 1970s to improve matters. In 1974 a revised School Library Act was promulgated requiring that a library be established in every primary and secondary school and vocational and teachers' training school and institute. The main school library was to support classroom libraries; in each school it was now expected that there should be a library committee of teachers and students to oversee its operation . The Ministry of Education's Department of Books and School Libraries aimed to provide about one book per student in the primary schools, and two books per student in the secondary schools . As a matter of policy, no books were placed in schools until a separate room was made available for them. However, the definition of what constituted a school library was clearly open to debate. Al-Amin reported that all secondary schools had libraries of varying sizes, but they were ignored by teachers, and students did not have the time to use them. Only a few experimental primary schools had small libraries, and even these apparently did not provide good service. A review of intermediate schools' libraries that appears to have been undertaken for the Ministry of Education during the mid-1970s reported that teachers and students were still focused on the use of textbooks; that the pedagogical system did not encourage independent study; and that most school libraries were poorly organized . At about the same time, a critical study of the state of school libraries in the Basra Liwa, presented at a conference in 1975, argued that the condition of school libraries could not be improved without significant changes in the educational system giving them an active and effective role . Zado confirmed that the system of education offered no incentives for students to seek out information; moreover, she commented that libraries gave no encouragement to students, and that there was no basic training for students in the use of libraries. A later report noted that the Department of Books and School Libraries was part of the ministry's Directorate of Curriculum and Educational Media . This seems to have provided a medium for at least potentially facilitating the integration of school libraries into the development of curricula and pedagogy. However, the law made the department, and a Central Committee on School Libraries comprising mainly high-level ministry officials, responsible only for • promoting school library service; • supervising, coordinating, following up, and reporting on school library activities; • maintaining records of book collections and their numbers of readers; and • organizing training courses for school librarians. In addition to the central committee, there was a school library committee in the Directorate of Education in each Liwa . However, Al-Werdi's opinion was that these committees were generally ineffective and contributed very little to the development of the school library service. He attributed this to a limited understanding of the planning and development of school libraries among the majority of committee members. The Ministry of Education issued and circulated a number of special regulations about the organization and maintenance of school libraries, emphasizing the importance of the school library and the need for adequate reading material in the class libraries to support the school program. The ministry's regulations emphasized that the library should provide adequate materials to support and enrich the school program. However, books that were selected and purchased centrally by the ministry or by the directorate of the local Liwa and supplied to school libraries at infrequent intervals rarely had any relevance to schools' educational programs or students' intellectual abilities . On only very few occasions were school librarians involved in purchasing books to meet teachers' requests . The ministry's guidance stated that students must be introduced to their school library, must be taught how to use the library catalog, and must be able to borrow books for reading at home . Few of these recommendations seem to have been put into practice. During the 1980s, although the publishing industry in Iraq contracted as the state budget was increasingly consumed by the war with Iran, there was a weekly magazine for children, called Majalati, and another for teenagers, called Al-Mezmar, and a series of popular children's books was also published, but otherwise children's books and magazines generally had to be imported from other Arab countries . This situation should come as no surprise. It has been many years since it was explained by Lorenz in 1962 that the shortage of books in vernacular languages in developing countries was partly a consequence of the absence of the basic market for the distribution of publications for which libraries' purchases would have provided the foundation, and it is clear that school and children's libraries were not strongly established in Iraq. The Ministry of Education claimed that its aim was for school buildings to reflect modern education, but Saef reported that the school "library" was still typically accommodated on closed shelves in a room designed as a classroom or else in a hall. The adoption of the Instructional Resource Centre concept in a school was expected to change the role of the librarian from being a guardian of resources, to facilitating access to resources. Mossa reported that the first IRC was provided for a technical secondary school in Baghdad during 1955-1956 by USAid, probably through an assistance project undertaken by Bradley University . Further IRCs had been founded in the 1950s and 1960s with the help of foreign experts, and by the end of the 1970s there were nineteen scattered throughout the country. However, they received little attention until the 1970s when the government began to experiment with new approaches to try to raise the quality of education. The facilities of the IRCs were generally limited, and most functioned only as media storage centers. In 1981 three meetings on the development of school and university libraries were held in Baghdad by the National Union of Iraqi Students , the Iraqi Teachers Union , and the Ministry of Education ). The origins, aims, and outcomes of these meetings are not known; however, it seems that the ministry subsequently established a working group to consider how to develop school libraries. 3 This may have led the ministry to start, in 1984-1985, a project to develop school libraries throughout the country, and some thirty-five had been converted to multimedia resource centers by the end of the decade . --- Developing Staff for School Libraries in Iraq Following Bonny's short training courses , one of the first activities of the new director of school and public libraries was to initiate and organize a study program for teacher librarians. Eighty-one students in the second stage of secondary school were taught some library science subjects, as well as others-probably the same ones taught to students intending to become teachers . This "Educational Course for Librarians" was a three-month program, with eight or nine modules, including "History of Libraries," "Classification," and "Procedures," as well as more general subjects like education and psychology. Students' assignments were graded, and the ministry retained records of their progress . Students were then assigned to secondary schools, teacher-training schools, and some primary schools. But the experiment was not a success, perhaps because of the trainees' youth and inexperience, and the ministry eventually transferred them to teaching posts in elementary schools . In addition, a conference of school librarians in the Baghdad Liwa was arranged for May 1960 and expected to be attended by seventy individuals. At some point in 1968, another Indian UNESCO consultant, Anand Srivastava, delivered lectures for a one-month teacher-librarian course conducted by the ministry. He later suggested that one of the roles of the Institute of Library Science that he had proposed for the University of Baghdad would be to offer, about every two years, a six-month program for secondary school graduates to work in school and other libraries, but the program does not seem to have been implemented . There were no qualified librarians working in school libraries at the beginning of the 1970s. Kalia , however, found that, in 1978 there were 150 secondary schools with full-time librarians. These were most probably teacher-librarians, although by that time some of them may have been graduates of the program in librarianship that had been established at Al-Mustansiriyah University in Baghdad in 1970. This Department of Library Science expanded rapidly, students from throughout the country being directed to it by the state's higher education system, although its graduates sought employment close to their home. Staff members with specialist expertise were not in much evidence in the seven IRCs surveyed by Mossa , none of which employing a librarian. The continuing use of teachers as librarians in school libraries may be explained by the shortage of qualified librarians that persisted throughout the country, as graduates sought better pay or status than library work, but the increase in student numbers had probably resulted in higher priority being given to the employment of teachers. In the budgets of Iraqi schools, as in developing countries generally, "the school library has had to compete with more urgent priorities such as securing a supply of teachers, textbooks and equipment. Usually the library ranks low in the list of these matters" . The World Congress on Books, organized by UNESCO in London in 1982, adopted a declaration titled "Towards a Reading Society" that asserted, "We seek a world in which there are indeed books for all, but one also in which all can read and all accept books and reading as a necessary and desirable part of daily life" . One of its recommendations was a further restatement of the importance of school and other libraries for stimulating reading, and the necessity of training librarians for this role. In Iraq, specialist staff members were few in number. Efforts by the ministry's Department of Books and School Libraries, which continued to actively engage in training teachers in the use of libraries and encouraging the formation of local library committees, had met with little success. The department's activities were handicapped by its own lack of sufficient, adequately trained staff; at the time, the department was run by three individuals, only one of which possessed a basic library qualification. The school library departments in the eighteen Liwas were staffed by twenty-seven people, of whom only twelve had training in librarianship . Article 7 of the School Library Act directed that "the recruitment of school librarians should be from among the teaching staff who have the interest, experience and previous library training, or from specialized librarians" . It seems that little had significantly changed by the end of the decade: "School Libraries are not well developed. The large secondary, vocational and technical schools maintain sizeable libraries administered mainly by non-professional personnel" . There were only eighteen qualified librarians in all school libraries in Iraq in 1981 . Almost all school libraries were run by teachers who were relieved of some of their teaching hours and entrusted with the duties of caring for and developing the libraries and training students to use them, but most had no library training, experience, or even interest. There were 277 full-time teacher-librarians who had mostly been given the responsibility of running the libraries because they could no longer teach for health reasons. In the other schools, 7,590 teachers, relieved from some of their teaching duties, acted as part-time librarians . Such teachers had little motivation and many disincentives; for example, librarians in all types of libraries had to pay for any books that were missing when the annual inventory occurred. In the early 1990s about 75 percent of approximately 2,500 secondary schools had a library, but many school libraries were without adequate premises, and only 131 primary and secondary schools employed a professional librarian . Because of the sanctions during the Saddam era that prevented Iraqi Kurds from studying librarianship in Iraq for almost twenty years, only twelve of 128 school librarians in Iraqi Kurdistan had any qualification in librarianship . Many school libraries did not offer any services because no staff members were deputed to manage them either full-or part-time . The Department of Library Science at Al-Mustansiriyah University had organized training activities for elementary and middle school library staff. No matter how limited this program was, it still made a significant change in librarianship in the country, according to one of the department's occasional lecturers . However, the quality of school libraries' services may have been rendered largely irrelevant by the social conditions that prevailed. All libraries were experiencing difficulty in retaining, recruiting, and motivating staff because of low salaries. There does not appear to have been a specialist professional association for school librarians in Iraq. It took several attempts before an Iraqi Library Association was founded. Despite its relatively small membership, it became sufficiently established during the 1970s to organize a program of professional activities and also to publish a journal, but its activities declined during the economic and political crises of the 1980s and 1990s. --- Recent International Efforts to Promote School Librarianship There was a flurry of international activity in Iraq during the 1970s, possibly partly prompted by interest in the perception of the potential for identifying school libraries with the trend toward multimedia resource centers. For example, IBE, which had been integrated into UNESCO's Education sector in 1969, was one agency that tried to foster the development of multimedia resource centers . The International Association of School Librarianship was founded in 1971, and the School Libraries section of IFLA in 1977. The participants in UNESCO's Cairo meeting on book development in 1972 noted that libraries, while potentially important in supporting reading, were generally underdeveloped. They pointed to the need for each school and community to possess at least one library with qualified staff and an adequate book budget, and envisaged the role of a proposed regional center for book development as including assistance in the national planning of school and public libraries and in training librarians . In "School Libraries in the Arab States," Aman implied that teaching methods in Arab schools were beginning to change. The issue of pedagogical styles in the Arab schools was certainly not being ignored. Participants in a UNESCO conference on education and planning in the Arab states, held in Abu Dhabi in 1977, endorsed a statement that the democratization of education means "imbuing its content, methods and structures with a new spirit of initiative, free criticism" . However, the learning resource support required to achieve this still seemed to be little understood. Sharif commented that generally the book collections in Arab school libraries would not support independent learning. During the 1970s, UNESCO developed two new programs: UNISIST and NATIS . The former, sponsored by its Science sector, focused on the greater availability and use of scientific information; the latter was a response by the Department de la Documentation, des Bibliothèques et des Archives to a recognition that recommendations by librarians had little effect on governments, and that development planners and policymakers were not sufficiently aware of the place of information in the development process. NATIS provided a framework for a strategic approach to integrating library development in national planning that seemed more likely to be effective in promoting libraries' development. However, participants, mostly librarians, at an Arab regional meeting on NATIS pointed out that the importance of school libraries was not fully recognized in the region, and that the development of their potential could only be achieved through the introduction of modern educational methods . UNISIST in particular had placed much emphasis on the training of information users. Arising out of a meeting on information use in higher education sponsored by UNESCO's PGI , a proposal was successfully made to IFLA in 1990 to establish a "Round Table on User Education." This became the Information Literacy section in 2002, and its activities subsequently attracted substantial support from UNESCO'S Information for All Program . The development of information literacy was seen by many librarians as an important opportunity to assert their role in supporting learning, but that opinion may not have enjoyed wider support. Research in UK secondary schools, for example, has revealed that "information literacy" is understood by teachers in isolation from the subject curriculum; they described it in terms of a variety of skills and processes that overlapped with existing models and frameworks, none of which included central elements in librarians' perceptions, such as defining the information need and knowledge-building . Information-handling skills were no longer peripheral to developing learning skills, but in Iraq and many other countries, teachers' awareness of the volume of information that was increasingly available and familiarity with how to help students build their own knowledge from it remained a gap in teacher education. A working group in the IFLA's School Libraries section prepared initial guidelines on how teacher education could respond to the changing information environment . The study was funded by PGI within the context of the training of information users, not by the Education sector, and was completed at a time when UNESCO was retrenching after losing more than a quarter of its income when three states withdrew from membership-two factors that may help explain why there appears to be little evidence of its recommendations being adopted. In August 1993 IFLA and IASL jointly organized an international seminar on school libraries at Caldes de Montbui in Spain, financially supported by PGI and other organizations. During the late 1980s and early 1990s, the IFLA's School Libraries section had issued guidelines on several aspects of school librarianship. Following the seminar at Caldes de Montbui, work began on drafting a school library "manifesto," which was eventually approved by IFLA in 1999. Later that year, with support from PGI, it was submitted for adoption by the UNESCO general conference and became the IFLA/UNESCO School Library Manifesto . As a follow-up to the manifesto, the IFLA School Library Guidelines were prepared "to assist school library professionals and educational decision-makers in their efforts to ensure that all students and teachers have access to effective school library programmes and services, delivered by qualified school library personnel" , which were endorsed by UNESCO in 2002. As Oberg observes, research on the impact of the IFLA/UNESCO School Library Manifesto and the IFLA School Library Guidelines has not yet been undertaken, although a number of experiential accounts of the implementation of national and regional guidelines have now been published . The participants in the seminar at Caldes de Montbui recommended that IFLA should seek to encourage greater collaboration between the relevant international and national agencies . As long ago as 1983, IASL had begun to openly acknowledge the need to develop closer relationships with other international NGOs involved in related fields and with other professions connected with children and youth . Following the seminar, efforts were made by IFLA to try to work more closely with IASL, including even raising the suggestion of trying to coordinate the venues for their annual conferences. In 2006 the governing bodies of both organizations eventually did formally recognize the advantages of working together, and IASL's and IFLA's School Libraries sections set up a joint working party, which managed to organize a joint event in the Caribbean before their separate conferences in 2011, when-coincidentally-they were both held in the same region. They have also pro-some issues facing many school libraries/johnson 237 duced two joint publications on recent activities in the field . --- Discussion A feature of many conferences and publications has been descriptions of school libraries in particular countries; these have served little purpose, lacking any critical analyses or explanations of how these situations arose. On the face of it, their problems are easily described. Zado , for example, claimed that the factor that was hindering the development of libraries and information services generally in Iraq was the lack of a reading culture, and called for changes in the education system, increases in publishing, and the promotion of user-education programs to raise information awareness and use. While not specifically addressing the limited ability of the Iraqi library profession to motivate the government to make these changes, she nonetheless implied that the assistance of international agencies would still be required. Discussing the challenges facing school libraries internationally, Knuth pointed to the dearth of books in vernacular languages, the barriers to the flow of books, the lack of infrastructure supporting school libraries and children's literature, and the lack of adequately trained personnel in school libraries. Having examined these issues in terms of the evidence from Iraq, the remainder of this paper aims to discuss their international relevance and how they might be overcome. --- The Reading Culture and the Education System It is widely recognized that teaching and assessment methods based on memorization do not inculcate the lifelong learning skills necessary to cope with the modern, continually changing world. They fail to foster a culture of independent reading, inhibit the development of analytical skills and the ability to make critical, objective judgments, destroy the inclination to search for possible alternative solutions to a given problem, and limit the creativity and innovation that could contribute to a nation's development. One "expert" described the state of education in Iraq as one in which "instruction had suffered from the Middle East disease: 'understand' means 'to be able to recite the textbook'" . Such criticism is inevitable, but ill-informed: teaching through memorization is only a manifestation of the problem, a symptom rather than the cause. It is important to understand the origins of the pedagogy to explain its continued existence in contemporary primary and secondary education. The evidence of history clearly shows that this pedagogic practice in Iraq is not a legacy from the tradition of memorization of the Qur'an in the kuttabs. In the twentieth century, Iraq's education system was confronted by intractable problems arising from the inability of successive governments to match growing resources to even more rapidly growing student numbers. Recruiting and training sufficient teachers was a major challenge. The state was the principal employer in the country, and there were few alternatives. British observers noted that teaching was an honored profession, but "too many enter it for the sake of the honour and not for the love of the work" . Trainee teachers who themselves had had a limited education were given equally limited preparation for the career ahead of them. It is clear that the demand for teaching staff as a result of the rapid expansion of the education system had constrained the introduction of new pedagogies that might have encouraged heuristic learning. The country's economic problems of the 1980s and 1990s then reduced the purchasing power of teachers' salaries. Many necessarily devoted time and energy to second jobs that could otherwise have been spent in preparing for new approaches to teaching. The numerous demands on the Iraqi state budget also meant that the school-building program could not be allocated unlimited funds, which resulted in school libraries remaining, at best, mostly small. The country's circumstances during the 1980s and 1990s highlight in particular the underlying issue for the government: that public-policy choices had to be made in allocating finite resources. Similar decisions confront all countries either because limited resources are available and/or because the decision-makers in government are not convinced that investing in school libraries is a priority that would command the support of the populationthe taxpayers and voters. Managers of private schools similarly have to consider the level of fees they believe that parents would be willing to pay. A study of private schools in Iraq suggested that many were no better than the state schools, both requiring better facilities and improvements in teaching practices , which underscores another issue that needs to be addressed; namely, public understanding of the costs and benefits of investing in learning. --- Book Publishing and New Information Media Another issue that cannot be ignored, and one that is as relevant in other less developed countries, is the state of the publishing industry. UNESCO's Education sector continues to encourage the provision of books for schools with its Books for All program, with which IFLA collaborates in determining the venue of World Book Day. The program encourages book production and equitable access to books in the member states based on the belief that reading is a fundamental human right. Nonetheless, there seems to be little wider appreciation of the detrimental impacts of an underdeveloped local publishing industry and book trade, which affect the potential for collection development by school libraries in Iraq and thus the development of a culture of independent reading and learning, as well as inhibiting library use generally. It seems equally certain that the role of the publishing industry as an element in economic development through its potential for scaling up from modest beginnings was negated by the Iraqi government's actions to control its output . Indigenous publishing is often further undermined by donations of books from foreign foundations, and also through bilateral aid programs that grant contracts for preparing and printing publications with companies in the donor country. Currently, there is a new and additional challenge. Participants in the seminar at Caldes de Montbui noted that "in the years to come, focus will be on developing skills and processes through the curriculum, not on mastering technology as an end in itself, which will in turn require more initial and continuing education of both school librarians, teacher librarians, information specialists, AND teachers" . The provision of new information and communication technologies has become a major feature in education, and especially in the international assistance provided for education in less developed countries. The forerunner of ICTs-audiovisual media-was not the success expected in Iraq largely because of problems with the availability of technical and professional support and suitable content. Although the new computer-based systems, when adequately networked, can improve the flow of information and data, their efficacy in enhancing learning are as yet largely unproven. Moreover, in the less wealthy and developed countries in particular, the availability of digital content suitable for use in primary and secondary education remains limited, and their technical and financial sustainability of ICTs is threatened. These issues need to be assessed openly and realistically. --- Information Literacy in the Curriculum During the 1960s, when the British Council was particularly involved in supporting the development of education globally, it felt that its efforts were "somewhat diminished by the apparent reluctance of teachers to abandon general reading for books serving solely their anticipated specialist interest" . There seems to have been little impact of the work initiated thirty years ago to encourage classroom teachers to integrate the development and effective use of school libraries into efforts to empower students "to take control of their own learning so that they will know how to learn in societies of rapid change and decreasing certainties" . Recent research identifies this failure as a continuing barrier to effective interaction between school libraries as providers of books and information, and teachers as potential stimulators of students' reading and research. The proposed IFLA/IASL revision of the IFLA School Library Guidelines place greater emphasis than the earlier version on the librarian's role in developing information literacy in students, but still fall short of offering pedagogical guidance for teachers on how to incorporate the development of these skills in subject curricula. --- Appropriately Trained Personnel Opinion among librarians in Iraq is strongly in favor of schools needing librarians, but little empirical data have been produced that might contribute to the debate about whether school libraries would be better served by librarians or teacher-librarians, and it is not one in which this paper will seek to engage. What is undoubted is that school library development would benefit from specialist personnel who have a wider understanding of not only both the pedagogical and professional/technical issues, but also the range of information products and services that could be brought to bear to encourage independent reading and enhance children's learning skills. The history of development in Iraq highlights the challenges in preparing and producing such a specialist workforce of adequate size and possessing appropriate knowledge, skills, and motivation. The literature also draws attention to the need for some of this knowledge and understanding to be embedded in all teachers' training. The efforts of both IFLA and IASL do not seem to address the wider range of issues involved, but instead focus narrowly on the professional/technical aspects. --- Mobilizing Support It is important to recognize that such progress as has been made in Iraq came about because influential officials within the Ministry of Education were eventually convinced that circumstances were ripe to provide a new focus on school libraries. The advice received by the ministry from visiting U.S. educationalists on the need to improve the library services in schools generally appears to have been ignored . An Iraqi official pointed out to Tesdell that an international expert's advice was of little value unless the expert stayed long enough to learn the reasons for present practices, to understand the complex obstacles facing any attempts at reform, and to help in implementing recommendations. It may be significant that the ministry acted after Bonny not only provided training for some teacher-librarians, but also presented an instruction manual that could be used by others. The effectiveness of international assistance was threatened because, according to the counselor for economic affairs in the U.S. embassy, "the general failure of Iraqi officials to grasp the need for government-wide planning and coordination causes duplication and waste" . Clearly, any arguments that are put forward to promote the development of school libraries must be placed within the context of a government's overall aims and plans; such arguments require their advocates to have an understanding not only of the politicians' agenda but also of the political system through which ideas can be presented to the decision-makers. The perceived failure of the committees that have existed at various levels in the Iraqi administration should raise questions about the extent to which the advocates of school libraries are involved, and the degree of understanding of the broader political and fiscal issues that they bring to the table. How to influence policy formulation is a challenge that the library profession has not yet fully addressed . The diversity in the field should not be underestimated . Individual countries face different challenges, follow different rates and patterns of development, and have differing resources, priorities, and capabilities. The skills required vary because of the numerous different audiences at which advocacy efforts need to be targeted, and the varying and sometimes overlapping interests of the different audience groups involved in the education field-politicians, administrators, teacher-trainers, school managers, teachers, and librarians-as well as differences in local organizational structures and managerial cultures. For this reason, Carroll argued that school librarians must be actively engaged in creating bridges among school libraries in their country, its education system, and its government's social policy if both national and international concerns are to be adequately addressed. While arguments need to be presented to decision-makers in governments and institutions in ways that enable them to recognize political advantages, the cases need to be underpinned by hard evidence. In the United Kingdom the groundwork for future research has already been done. A number of critical studies have critically reviewed the research evidence available in the English language on school libraries' impact on attainment and learning and the socioeconomic benefits derived; have identified the items that support the case for enhancing school library provision and use; have highlighted gaps in the evidence; and have examined the methodologies used . These reviews need replicating in other countries to identify any gaps in the coverage of studies in other languages. Oberg , observing that the complementary strengths of IASL and IFLA should be harnessed to enhance the provision and use of school libraries, defined IASL's role as encouraging its 500-1,000 individual members to provide the research evidence to underpin the debate. IASL could play a useful role in encouraging further reviews along these lines and providing a framework that would ensure some compatibility among the resulting reports that emerge from different countries. Knuth highlighted that although there was an element of crossrepresentation in the memberships of IFLA and IASL, and occasionally common leadership, the lack of coordination among all the international agencies in the field was an obstruction to progress, as they mostly work separately toward their particular goals. As Carroll notes, "The issue seems to be whether the leadership of organizations related to school librarianship will respond and improve communications to move their memberships toward a tremendous professional opportunity." --- Engaging the International Associations and Agencies International organizations should be able to reflect the diversity of national circumstances, but have a responsibility "to prepare materials that indicate its acceptance of plans by a majority of nations" . At the time of writing, IFLA and IASL have been collaborating in drafting a revised version of the IFLA School Library Guidelines, and these await adoption by UNESCO. Oberg acknowledged that using IFLA's formal relationship, as one of only forty-two bodies granted associate status by UNESCO, was necessary to advance the cause. The apparent retention of IFLA's name in this document may be intended to smooth its path through the UNESCO approval process, but otherwise could perhaps appear inappropriate to some IASL members and may detract from its acceptance within the wider educational arena. It does, however, seem that some sense of the political realities is at last entering the arena. In discussing the revised guidelines, Oberg also acknowledged that "both the educational and cultural sectors of UNESCO would have to be involved in the approval and implementation of the document." IFLA's relationship with UNESCO has hitherto focused almost exclusively on part of what is now the Communication and Information sector, a part of the organization that has been openly criticized in recent years for its internal weaknesses, notably in the relevance of its current skills base . A longer-term review might also have pointed to shortcomings in the leadership provided by the managers in UNESCO's library and information field in many periods during the last seventy years. The organization's support from its regular budget for its changing organizational manifestations in the library and information field has never been more than barely enough to enable them to experiment with, demonstrate, promote, and advise on advances in the field. Its limited budget is now increasingly disappointing the many member states who had come to expect it to provide the higher level of substantial technical assistance that UNESCO was able to access through the UN Development Fund to support major projects between 1965 and 1990. It is clear that IFLA now needs to use its position to establish a stronger link with UNESCO's larger and more influential Education sector if it wishes to promote school libraries more effectively. It is also clear that, while IFLA and IASL have recognized the need to work together, they cannot do it alone. Bridges have to be built by both IFLA and IASL with other international bodies in the field such as ILA to motivate them to work together in advocating school library development to the decision-makers in the relevant agencies of national governments and intergovernmental agencies. The range of organizations linking children and books is more substantial than might appear at first. Through the organization of the annual World Book Day events, IFLA and IASL already have some contacts with IBBY, founded in 1953, which includes publishers of children's books among its members, has consultative status with UNESCO, and like IASL has a strong basis in related national organizations. In addition, Knuth suggested the International Youth Library , founded in 1949, as another key organization with a reach that extends to other specialist organizations interested in children's literature. --- Conclusion This paper has reviewed the salient features of school library provision in Iraq within the context of the circumstances that influenced its development as part of the country's education system, particularly during the twentieth century. It has explained that the token gestures made toward the provision of school libraries and encouragement of their use in the country were not a consequence of the absence of a strategic vision of how to develop the culture of independent reading and critical thinking that underpins continual learning; rather, they were a result of the government's tactical decisions about priorities in the allocation of finite resources when faced with a range of increasing demands on the state budget. It has also pointed to shortcomings in the recommendations proffered to Iraq and other Arab states by international professional and intergovernmental organizations in terms of their immediate relevance, practicality, and lack of demonstrated benefits, as well as the absence of consistency and unanimity in those recommendations. At IASL's conference in 1972, participants were asked to consider how they could help "to bring about better support for the basic concept of libraries-the center for information -on the part of administrators, Ministers of Education, community leaders and parents" . While current efforts by the supporters of school library development appear to be slowly heading in the right direction, it is regrettable that they seem to be doing so without a more widely shared agenda that addresses all the issues. Support for school libraries will be mobilized only if politicians hear a consistent message from all the interested parties that it will be seen to benefit the country; decision-makers in governments are convinced that the costs will be offset by sufficient economic benefits; and teachers fully appreciate that improvements in learning can be derived from implementing relevant pedagogical methods while fulfilling the requirement to expound the content of their curricula. One obstacle to progress seems to lie in the predominance of library associations in promoting this dialogue, and their limited engagement with the teaching profession through bodies like ILA and with the bodies concerned to promote the development of the book trade. A starting point for any future efforts to promote school library development by the wider alliance suggested in this paper seems to be an understanding that policy choices have to be made when resources are finite, and that the challenge is to get school libraries visible on the policy agenda and raise their status. There are mechanisms for achieving these that the advocates of school libraries could adopt or adapt from other social sciences . It seems important to recognize that the aim of governments is the well-being of the community they serve, and that this depends first and foremost on their economic well-being. Clearly identifying the provision and effective use of school libraries as a cost-effective item in the agenda for national development is an essential element in securing political support. Another is fomenting a groundswell of supportive public opinion, based on instilling an understanding of how the effective use of school libraries underpins development of the lifelong learning skills that contribute to individual prosperity. However, these efforts will not succeed without successfully encouraging all teachers to work together with librarians to foster the independent use of information, and without evidencing the links among information use, learning, and development. It is also clearly important that the case being made is directed at influential elements within national governments and international agencies instead of being wasted on weak or failing bodies, as seems to have been the case in recent years. --- Notes 1. Muriel Strode [Lieberman] , "Wind-Wafted Wild Flowers" . 2. This information, and much more, was edited out of the final version of his report by UNESCO headquarters staff before it was sent to the Iraqi government and published the following year because the terms of reference for his mission focused exclusively on the potential for developing a postgraduate degree program in librarianship at the University of Baghdad. 3. Notes made by the author from a conversation in Amman with the director of the Baghdad Documentation Centre, A. K. A. Jabbar, during June 13-17, 2004, and from Professor Jabbar's curriculum vitae.

This paper discusses why many school libraries may not have been seen as an essential element of education, and supported and used accordingly. It reviews the international agencies' advice and encouragement for the development of literacy, education, and school libraries, particularly that focused on the Arab world, and considers the provision of school libraries within the context of a country's economic, political, and social circumstances, with Iraq as a particular focus. From this evidence, it discusses the reasons why school libraries remained underfunded, inadequately staffed, and little used, and what appears to be needed to transform the perception of their contribution to a country's development, briefly reexamining the interactions between the education system and the training required by all the personnel involved in the development of a reading culture, the role of book publishing and new information media, and the place of information literacy within the curriculum. Finally, it draws some conclusions about issues in mobilizing support for development, and points to the lack of a focused and coordinated effort by the relevant international agencies. The paper draws on a wider case study of the development of librarianship and information management in Iraq, which is expected to be published shortly.

Background Nigeria is multi-ethnic with diverse cultures due to the various ethnic groups. The major ethnic groups are the Hausas based in the north, the Yoruba's in the southwest and the Igbos in the southeastern part of the country with Christianity and Islam as major religions in the country [1]. The country has rich human resource with a population of about 202 million people, has one of the largest youth population in the world, an abundance of natural resources, the biggest oil exporter and has the largest natural gas reserves in Africa [2]. Nigeria was not left out of the global economic disruption; the economy of the nation depends mainly on the oil sector which made the nation's economy vulnerable with the advent of the C0VID-19 pandemic as a result of the massive decline of oil price during the pandemic [3]. Furthermore, eighty three million Nigerians accounting for 40% of the population live below the poverty line, 53 million are vulnerable to poverty and with the ongoing COVID-19 pandemic, many of these 53 million vulnerable people are liable to fall into poverty [3]. The high inflation and unemployment exacerbate macroeconomic risks, and activity in the tertiary sector will not fully normalize unless the pandemic is contained [3]. Public Health is relevant to national security, despite the huge development in the health care sector there is need for improvement as shown by the various health indicators in the nation. Challenges faced by the sector such as financial managerial competency, inadequate funding and limited human resources is likely to increase the impact of the pandemic [4][5][6]. The impact of the pandemic on health will be dependent on the duration and spread of the pandemic [3]. Abuja, the capital city of Nigeria and has the second highest number of cases in the first wave of the COVID-19 pandemic [7]. Despite the challenges and hitches that arose in the health sector as a result of the pandemic, the health sector was able to handle the situation with the help of the government and other nongovernmental organisations that supported the health sector with PPEs and other equipment's [8,9]. Frontline healthcare workers are at highest risk of being infected. These are people working in health institutions providing direct care and treatment services in order to save lives in their communities [10]. The duties of FHCW in the face of COVID-19 pandemic has taken its toll on them considering the fact that there are many unknown variables regarding the novel corona virus infection. Stigmatization is one of the major issues associated with the highly infectious novel corona virus pandemic [11][12][13]. Among the challenges faced by these frontline healthcare workers are stigmatization, resulting in psychological and emotional trauma on the person that is being stigmatized [14]. Stigma has a high impact on healthcare workers outcomes [15]. Working with patients that possess the potential of being highly infectious such as the COIVD-19 pandemic serves as a means by which stigma is generated [16]. Several studies have indicated that stigma associated with COVID-19 is a major source of psychological trauma resulting in stress, anxiety and depression among FHCW with adverse health implications [17][18][19][20][21]. A systemic review with meta-analysis revealed that all the articles studied reported on stigmatization as a result of work-related COVID-19 exposure [22]. Studies have revealed a high prevalence of stress, depression, anxiety and mental disorders among FHCW in the COVID-19 pandemic [23]. There exist a global barrier to health seeking behaviour as a consequence of stigmatization [24] propelling diverse forms of discrimination mostly resulting in reduced or absence of social acceptance or opportunities to specific individuals or groups of people. Moral injury is a product of intense psychological distress from actions or inactions violating an individual's moral or ethical code [25,26]. The advent of potentially morally injurious events may consequently produce negative thoughts about oneself or others along with deep feelings of shame, guilt or disgust [27]. Consequently attributing to the development of mental health problems such as depression, post-traumatic stress disorder and anxiety [27,28] The FHCW trying to save lives and protect society may also experience social distancing, changes in the behavior of family members, and stigmatization for being suspected of having COVID-19 [29]. Qualitative methods are most effective in capturing social responses to the COVID-19 pandemic as shown by other epidemics in the health sector [30,31]. Such methods permits the capturing and comprehension of how people make meaning and sense of health and illness [30,31]. Despite the struggles of FHCW in the COVID-19 pandemic in Nigeria, there is no psychological counselling readily available for the FHCW who are faced with the challenges of increased work stress, depression, anxiety, stigmatization and mental trauma. There is need for instituting measures to handle these challenges. This study explored the experiences of the FHCW during the COVID-19 pandemic in Nigeria. --- Method The aim, design and setting of the study The University of Abuja Teaching Hospital COVID-19 isolation centre is located in Gwagwalada. It is one of the seven isolation centres in the Federal Capital Territory . The centre is responsible for handling patients that have moderate to severe symptoms of COVID-19 infections in the FCT. It is a 42 bedded capacity isolation centre and was the first hospital in the FCT to manage patients with COVID-19. Majority of cases from this centre were referred from other isolation centres in the FCT for specialist care. We aimed at determining the challenges faced by the FHCW in Nigeria in the COVID-19 pandemic; there psychological and mental state and their means of coping in the face of the pandemic. The research questions were: Are FHCW in Nigeria battling with stigmatization and psychological trauma? What are the measures that could help in resolving these challenges? We conducted a qualitative study on FHCW at the UATH isolation centre, Gwagwalada, Abuja. The inclusion criterion was FHCW working at the UATH isolation centre, Gwagwalada. The exclusion criteria were inability to participate in two or more interviews by a person within the study period. Purposive and snowball sampling were used in the recruitment of participants. We conducted the study from the 14th to 29th September, 2020 and determined the data "saturation point"; when there was no new information generated from the interview. Duration of interviews ranged from 5:48 to 19:47 min with an average interview time of 10:42 min. Twenty FHCW working at the isolation centre were interviewed . Face-to-face in-depth interviews for all participants was used to collect data. We adopted this interview method for the participants' privacy, confidentiality, exploration of individual views and provision of in-depth information. This method was also more suitable for sensitive issues such as stigmatization and mental health challenges in the face of the ongoing COVID-19 pandemic. The public health advisory on physical distancing, use of face mask and hand hygiene were observed throughout the interviews. We used a SONY ® Stereo IC Recorder ICD-PX470 to record all the interviews which were conducted in English language. Obtained recording was transcribed verbatim to effectively communicate the experiences of respondents. --- Interviewer guide We used an interviewer guide to keep to the scope of the study and ensured that the same stream of guided questions was responded to by all respondents. Questions used for the study were adapted from previous studies [14,32] and modified to suit the current study. All authors reviewed and approved the interviewer guide. The guide covered areas like: 1. Introduction of the interviewer. 2. Sociodemographic characteristic of the respondent . 3. What are your insights in the face of the COVID-19 pandemic [32]? along with further probing questions Please tell me your perception generally about the COVID-19 pandemic? How did you feel when you heard about the global impact of the disease and when it finally reached Abuja, the Federal Capital Territory of Nigeria? How did you feel when accepting the COVID-19 outbreak task [32]? How do you feel when working with COVID-19 patients [32]? 4. What are your thoughts and feelings regarding this task [32]? 5. What are your challenges so far regarding your mental health as a frontline health worker? 6. Did the COVID-19 pandemic affect the performance of your duty as a frontline healthcare worker in any way? 7. Do you feel stigmatized in any way [14]? Any form of stigmatization by family members [14]? Have you experienced any form of stigmatization by your colleagues [14]? Did you observe any form of stigmatization by your community [14]? 8. Any idea or reasons for the stigmatization? 9. What are the measures that can be taken to alleviate what you are passing through [14]? 10. Do you have health insurance? Probing questions like "Can you please throw more light on that?", "Can you please explain?", "Please tell us more?" were used to enhance the depth of discussion. --- Data analysis We carried out qualitative analysis of our data using the Colaizzi's phenomenological method [33]. We analyzed our data using the seven vital steps of descriptive phenomenon while sticking to the content of our data by familiarizing ourselves with the data through identifying significant statements with direct relevance to the phenomenon under investigation, formulating meanings, clustering of themes, developing of exhaustive description of the phenomenon incorporating all the themes produced, producing the fundamental structure and finally, sought verification of the fundamental structure by some of the participants' [33]. Participants that verified the fundamental structure of the analysed data approved of the findings. The interview data set was manually coded using inductive coding method [34]. Initial response and observation was used to construct a coding scheme based on the major categories that evolved [34]. --- Results The demographic characteristics of respondents on sex, marital status and identification is shown in Table 1. --- Theme one: early stage of the pandemic The early phase of the pandemic was characterized by anxiety, socio-economic impact, a call to duty for the FHCW and the need for more engagement by the government in the fight against the pandemic . --- Subtheme: effects of the pandemic The effects of the pandemic expressed by the respondents were; repatriating of foreign citizens', worries about the country's level of preparedness, skepticism about the future of the country, anxiety, public fright and high impact on life; economic and social aspect . Others view the situation as a professional responsibility and the need for the government to step up its support in fighting the pandemic . Some participants narrated their experience as follows. "In February, we had people who were suspect cases but were never confirmed. By March, there was anxiety all around, there were a lot of uncertainties too; people didn't know what to expect, people were not sure, there were lots of predictions with regards to Africa, lots of predictions with regards to Nigeria. We saw foreign countries repatriating back their citizens, there was a lot of fear and anxiety in the air. For us, it was not any different because we knew we were going to face those cases when they come over. On our path too, there was a lot of fear because this is the first time we are experiencing a pandemic like this. We were also worried about our preparedness; can we sustain the tempo? can we sustain the esteem? All that we heard of in terms of protection; are we going to receive protection? Was it going to be there for us all the time? Our families? So? Yeah! A whole lot! It was climaxed with lots of uncertainties but we were just looking forward to what the deeds are going to unfold in the future" . "It is worldwide, it is global and cuts across every aspect not only in terms of education. It has put the whole country in a standstill, and is one of those things that I have come across that everybody's hands just have to be on desk to ensure that we curtail the disease" . "It is a global emergency; a new disease that just came out which we have not really understood it very well and the impact on lives, economies and social aspect is much. It is something that has no regard for any nation whether developed or under developed and requires prompt attention because of the highly infectious nature of the disease. We are equally privileged; we are among the frontline health workers that are battling with the pandemic. Although the task is much, but with equipment and dedication we are winning the battle" . "It's a novel disease that we are not familiar with and because of that, when it came in, there was so much fear when we started seeing it in other countries, so that fear has been in us, in our families, until when it came into the country, and with the casualties we are seeing in other countries, we were also having that fear that it might also happen in our country" . "When it came it was scary, even now, though we are not that scared, we are very much careful with what we do. The pandemic is seriously affecting people's lives and we have to be careful about it and know how to go about doing our jobs" . --- Subtheme: a call to duty The FHCW felt that it was their duty to engage in the care and treatment of patients. Some saw it as a privilege and honour to serve their country and a challenge that needs to be addressed . A respondent was skeptical on accepting the task while another respondent expressed disappointment in loosing of clients on accepting the task . Some of their responses is narrated as follows. "Well, the task is on infection and my specialty is in infectious diseases, so, it's something I wouldn't mind on me and I had to participate. Though it was said that it's optional, but it will not be nice for me to reject the offer. It is something that you have to do if it comes to your field of profession. So, I didn't feel anything negative about it, it's okay" . "I felt it was something I had to do being an infectious disease physician and we are dealing with an infectious disease. So I felt it was my duty to be part of the team even though I was not forced to be part of it, I accepted the challenge. Of course there was this fear of the unknown, we were dealing with the pathogen we have never seen before and there was a lot of fear associated with the virus. I was afraid that I might get infected along the way but even with that I felt it was my duty to be part of the team" . "For me it wasn't difficult because of the initial reservations I had; I really didn't think it was going to come, I thought it was going to be like what we had in previous epidemics that occurred in which we were spared. I thought it was going to be the same kind of setting but certainly I knew if called upon, I was going to respond. By virtue of training, I am a respiratory physician, I knew very well that COVID affects the respiratory system. Is like having a military general who is asked to go to war and he says, he is not going because of fear or something. For me, even though there were uncertainties, I was looking forward to the challenge. There aren't much reservations really. From the beginning, I have calculated the risk and I just felt that it was worthwhile accepting the task. For me, it was more of if I could just make an impact where I can save people. I wasn't even bordered about what the outcome for me was going to be. It was a challenge I picked from the beginning and I was looking forward to doing it" . "Well, I see it as a good experience. Yes, I was brought in by the management and initially I felt skeptical because I felt I am a gyneacologist, so, what am I doing with infectious disease but considering the fact that nobody is immune to this disease, everybody can be exposed, we had pregnant women, we had some postpartum and antenatal patients that have been exposed to COVID. So, I see it as a wonderful experience when I came in, I discovered though we had less than ten of such patients since inception but it's a wonderful experience and I picked up the challenge" . "I didn't think twice because somebody has to do the task and the knowledge that God has deposited on me is not for the fun of it and failure to use that knowledge is also a sin in the sight of God. I have been endowed with the knowledge and I should be able to use it to save others" . "Well, I feel it is an honour and a responsibility to the profession, to the country and generality of humanity at large" . "Well, as someone who specializes in microbiology and biomedical virology, I feel it's a challenge to me to go in there and see how we will fight it out because that's my area of specialization" --- Subtheme: treatment of FHCW Participants expressed the need for the government to show concern to the FHCW; the need for emotional support and motivation . They also expressed the commitment of the hospital management in meeting the needs of FHCW . I am exhausted, I feel frustrated and sometimes I feel like I should dump the job. In fact, I feel neglected, I feel there is nobody apart from my friends that has ever bothered to enquire about how stressful it has been or how I cope with the task. Nobody has done that at all levels, in fact, people try as much as possible to evade or to pretend not to notice so that they don't give me an opportunity to even talk about it, to bring up a topic or issues that may disrupt the work, but if you need the work to operate smoothly, I feel engaging and interacting with the staff is essential. As I have said, from government downwards this is what I have experienced; in fact, the only thing sometimes you get from government, is not that is official, something perhaps I cannot confirm and cannot say with degree of certainty is, that there are perhaps certain threats that you must do this, it's your work. Yes, it's my work but not to the extent of just risking my life. I feel that some people feel that they are at the realm of affairs, at the top and have never bothered to even visit from a distance, to say, that is an isolation centre and wave to the staff and enquire; how are you? They have not done that and have severed themselves from us based on my understanding-" . "From the hospital management, our management has been supportive in trying to meet our needs, the needs of the frontline healthcare workers working at the isolation centre. From the side of the government, they have provided some support such as the materials that we are working with like the PPE, consumables and all that; we've had support and we have not lacked materials to work with. Regarding emotional support, we have not gotten because nobody from the side of the government has bothered to come and find out what we are doing and what has been our challenges so far. Financially, we've not really gotten much support from the federal government, they promised to give us additional 20% of our basic salary to all the frontline health workers, they paid for 2 months and that was it; based on the number of months we have worked here it's really not encouraging with regards to this aspect, the government has not done well" . --- Theme two: working with COVID-19 patients There were various experiences with regards to working with the COVID-19 patients as indicated in Table 2. --- Subtheme: taking care of patients Participants were excited working with people recovering from COVID-19 which was associated with their healing while taking care of them . Some of their experiences is narrated as follows. "I feel very excited to work with them because I see some of them coming in a very bad state, we commence treatment, they get better and go home. I am very happy because I see them come with a lot of symptoms, we commence treatment and they get better" . "Oh great! If there is anything that gives me passion is to count myself among the people who give other people hope to live. To me, it's a privilege" . "My relationship with the patients has been cordial because the disease can infect anybody, it doesn't respect who you are, where you are from. So, that they are COVID positive doesn't mean that I am better than them. I didn't really feel somehow, all I need to do, is just to put in my best, put on protective measures such as the PPE, well kitted, go and see them, talk to them like we have known each other before and this has given them some form of psychological support. For the patients to leave their houses and come to the isolation centre, the stigmatization they might have experienced in the society and coming to the hospital environment, if the healthcare workers stigmatize the patients, it may deteriorate their condition or psychologically affect them. Mostly, when I go, I relate well with them, talk to them, reassure them patterning their state of health, treat them and most of them feel happy about the care they are getting especially those that came from other hospitals. There was a patient that said; wow! You mean you people can come and talk to me and touch me? She was impressed because from the hospital she was coming from, nobody bothers to come close to them. Here we are, not just coming close to them but on several occasions, we just pat them, like reassurance, saying, don't worry, you will get well, so, all those things also helped" . --- Subtheme: types of patients Some of the patients were described as accommodating while others were difficult to work with . Majority of the patients that were admitted in the isolation centre had difficulty in accepting their disease status, they had to be counselled before accepting their disease status . Some participants narrated their experiences as follows. "Ah! That's a damn lot of issues now. Well, you know, they always come in different forms based on their approach to issues generally. Some do understand with you, so we could categorize the patients. For instance, back then we knew that some had this notion that you are doing a government job; so, their whole attitude was, you just do the job irrespective of the safety measures and mechanisms that we put in place. towards the services we were rendering. We were the second isolation centre, so when we accepted the task, there wasn't any health insurance, there was nothing, we just accepted the national assignment. So, when you hear some of the patients talk about us, as if is something that was optional to us, it is a little bit discouraging, you source for strength for yourself and keep pushing" . "Initially, most of the patients need to be convinced that this virus is real. At first, none of them will believe and tell you that; I tested positive. That is the first difficult task. Eighty percent of them that come, don't believe that they have the virus. So, as a nurse, the first thing I do is to counsel the patients and inform them on the disease and the mode of transmission and the need for them to accept the test result. The anxiety they have in accepting that they have COVID, is what makes is necessary for us to counsel and educate them, before accepting their disease status and we take them into the ward. The first 12 to 24 hours, there is anxiety, high level of fear and rejection. After 24 hours, they relax their minds. The environment too contributes and you see that interaction with them helps. We take all our patients as family and that is the joy in this place. That family attribute, discussing with them one on one, seeing how we take care of them, talk to them, come close to them; the rejection that they feel from outside is no more there, so they feel at home and that is what gives us our quick recovery of patients in this centre. Most of the patents testify to that . --- Subtheme: enormous task Participants expressed fear of being infected and discomfort when wearing PPE for long duration while others described the task as enormous . The experiences of some of the participants is narrated as follows. organizations and all the ministries were resting at home without coming to work, everywhere was shut down, even when there was ease of the lockdown, they come to work once in a while. We are coming every day, 24/7, no weekend, no Saturday, no Sunday, yet we are doing it, believing that God is a rewarder" . " Theme three: psychological, mental and emotional trauma Respondents were psychologically, emotionally and mentally challenged while carrying out their duties . Some respondents were psychologically traumatized; they felt exhausted, frustrated, neglected, demoralized and depressed. Other challenges include lack of health insurance for FHCW at the isolation centre, discouragement from doing the job by their loved ones and emotionally down due to the death of some of their patients. Some of their struggles were movement restriction, separation from family/friends and cutoff of relationships . --- Subtheme: psychological and emotional trauma A respondent felt discouraged and withdrawn when his colleagues at the isolation centre tested positive; which made him not to come to the isolation centre for some days . A respondent had psychological fear of dealing with a highly infectious virus . Some of the participants narrated their experiences as follows. "Sometimes I get depressed and depression sets in when I see one or two of my colleagues who we started this work with coming down with infection and you would expect that we have a good health insurance coverage that will carter for these people and it's not just there. The people will have to source for their own treatment themselves and you start thinking, is it really worth all the struggle? So, at some point in time, when I am faced with some of these experiences, it really, weighs me down and I start thinking that maybe I should have a rethink on the whole thing" . "When we talk of performance, the one that really affected me was when I discovered that seven of my colleagues were infected. We had to admit them and these are my colleagues we were walking with day to day. --- Subtheme: mental challenge Some of the experiences of participants regarding mental challenge is narrated as follows. "Mental health has been a big challenge, initially when we started we were not going home to our families, that was a very big issue because staying away from your family for months is actually a very big challenge, for me, that was an issue" . "The first challenge is being confined to a room and separation from my family. The truth about it is when we started, we spent more than 2 or 3 months without seeing our loved ones. From the isolation centre, to our hotel room, from the hotel room back to the isolation centre. The first time I saw my loved ones, everybody was scared of coming close to me because they just believed that if they touch me, they will be infected. That mental ability of curtailing that rejection from my own family and my colleagues at my place of work, it really weighed down on me but with time I picked it up and said these are some of the challenges I have to face; and that gave me courage. Later on, they started coming back to interact with me" . --- Subtheme: stress Some of the stress encountered by participants in performing their duty was the log duration in wearing of personal protective equipment and fever . Narration by some of the participants is presented as follows. "There is difference because before at our various departments, we don't need to put on PPE while attending to patients, but now before going into the isolation centre, we have to put on complete PPE which is discomforting; we have to stay like 30 minutes, an hour, two hours, so, it's really affecting us" . "When we started about a month or two, it was a kind of fever experience, I don't know whether the fever was as a result of anxiety, fear or whatever, I really don't know. Three of us working in the laboratory, had fever and we took medications. We don't know if it was COVID but we called it fever because none of us tested for COVID. Mentally we assumed that anything can happen since we will be dealing with COVID. A day before I came, there was a consultation I had with heaven and God gave me a verse that settled my mind; lo, I will be with you and nothing will happen. I don't think of anything outside God who has given me the assurance; I don't have fear" . --- Subtheme: priming the mind A respondent expressed the need to brace up in living with corona virus . The participant narration is as follows. "Well, in my opinion, COVID-19 is something that will not be eliminated easily and we have to just prepare our minds to live with it" . --- Theme four: stigmatization All respondents felt stigmatized while working at the isolation centre . --- Subtheme: stigma associated behaviours Participants were stigmatized by family, friends, colleagues and their resident communities . Some of their experiences is narrated as follows. " "Yes! Some of them will tell you that, had I known that you will work at the isolation centre, I would not have consented from the beginning. I had to tell them and educate them that it is not a death warrant, even to the victims as well, there is hope for them. if some of us back out, what of the patients that are out there? Who will be there for them? It could be them, it could be we and if everybody backs out, who is going to do the job? So, sometimes, you have to take responsibility" . "Yes! Yes! The issue of stigmatization is there; from your family, from your colleagues. When we started, you cannot even cross to the main hospital, everybody will be running away from you. I remembered when I went there to pick something; I was reported straight to my coordinator; they warned me not come close to their unit; I should remain in the isolation centre. Later on, when they found out that the disease was not just community spread but also hospital spread, they felt they were more at risk than those of us working at the isolation centre, so they became friendly. That stigma was there and everybody was scared of people working at the isolation centre" . "The stigmatization is that they assume you are a corona patient, even within the hospital. In fact, initially when we started working in the laboratory at the isolation centre, there were some things we needed to get from the main laboratory; when they see us coming, our colleagues will run away from us because we work at the corona centre. It is assumed that you are infected and you are coming to infect them. These were the experiences we had at the initial stage. Up till now our colleagues are not comfortable being around us; they always point to the fact that we work at the corona centre, because they know we are working at the corona centre. The fact that we work at the corona centre is a problem" . "Much! Much! Some people that know that I am working here totally don't want to associate with me. last week, I went to a compound to fetch water, tap water, in the compound they know I am working here, the owner of the compound, the woman, asked me not to touch her tap, she called her son to come and open the tap for me, the only thing I touched was my gallon that I came with, even her gate, they opened it for me. So, I was embarrassed but I am aware of the issue of stigma in the community as a result of the pandemic" . "I had challenge with my community. The head of the community met me and told me that since I am working at the isolation centre, I have to leave the community because of the information they heard about the virus. It was something scary and since I am working at the isolation centre, I might get infected with the virus, bring it to the community and spread it. So, they need me to leave the community for the period of time I will be working at the centre and for them to observe the trend of the pandemic. So, I left and I thank God for the management that provided a place for us to stay, that was when I felt relieved" . --- Subtheme: effects of stigma Some respondents had to withdraw themselves from family, friends, colleagues and their residential communities due to the ongoing stigmatization of FHCW working at the isolation centre . Some of their experiences is narrated as follows. "When we started even our colleagues that are healthcare workers and are not part of the isolation centre workers do not interact with us. Even now, some don't feel comfortable interacting with us. So, because of that, it has restricted what I do and where I go. I am withdrawn most times because I don't want to go to where I know people will stigmatize me because I work at the COVID isolation centre. Some people see us as people who can infect them. I tried not to go to some places so that should there be anybody that gets infected with COVID, they will not subsequently link it to me and blame me as a source of infection to that person. So, the stigma especially from health care workers is there" . "Even at home, my neighbour since he knew that I work at the isolation centre, stopped my children and grandchildren from going to his house and stopped his family from coming to my house. Some people from my state and people I know very well that used to come to my house stopped coming because I work in the corona virus centre. I think I am viewed as infected or possibly carrying the virus on my body, I don't know. I stopped visiting, I don't go to people's houses, I manage to go to church and I have a corner I sit, I don't stand up to go to places in the church, once the service is over, I go straight to my car, wait for my family members and drive away" . --- Subtheme: reasons for stigmatization Reasons for stigmatization narrated by some of the respondents ranges from fear of getting infected, limited or the lack of knowledge and working at the isolation centre which has to do with treating and taking care of people recovering from COVID-19 . Some of the respondents that stated fear of infection as one of the reasons for stigmatization narrated their experiences as follows. "It's fear; fear of getting infected. They are afraid of getting infected and they know that this infection doesn't have a cure. So once they get infected, they are thinking that their chances of dying are high. So, as much as they can, they should avoid anything or anybody that can expose them to the infection; health care workers at the isolation centre, have a high chance of transmitting infection or getting infected if there is any breach in the COVID protocol" . "I think it is just the fear, it's better now. Back then at the onset, with the prediction and what was happening, thousands were dying globally, we were seeing thousands needing ventilators. So, of course, every other person around too was afraid. If I come down with COVID, there is some uncertainty; will I survive? will I die? The real issue will have been the fear factor; people were not sure of what to expect" . "I guess is because of the fear of the disease, the high infective rate of the disease and the possibility of death. Nobody wants to die, because they think by going closer to them, I will infect them. They felt that if I am going inside the isolation centre, I may be a source of infection to them" . "Of course, I think I know; one is because everybody is scared and they think that once you get the disease, it's a death sentence. If you are coming close to them, they think you are coming with the disease not knowing that with the knowledge you have gathered, you know all the necessary percussions to take. They even think that when you talk to somebody on phone you will be infected. Your coming, they see you as a danger to their own health. I think there is need for more sensitization about the disease. They should know that there are precautions you can take while you are in the mist of other people" . "Because of the deadly nature of the virus, people are scared, they know that once they come close to you, or you come close to them they will get the virus if you are infected. That is why the people are scared but now that they have been enlightened, the level of stigmatization has reduced" . "Of course you know as a pandemic, everybody is afraid, so that he or she will not fall victim. Immediately they say we are the frontline health workers working at the isolation centre here; any time they see us, they don't want to come close to us, they will be running away from us, despite wearing of facemask, they are still running away from us" . "Uhmm! The reason people are scared is because they know that I work here. They think I must have been infected and since they think the disease is air borne, by going close to them, they will become infected. Now, I think the scare has reduced" . Some of the respondents attributed limited knowledge of corona virus as the reason for their stigmatization and narrated their thoughts as follows. "Lack of adequate knowledge about the disease, because we should not be people that are stigmatized but people that are celebrated, at least for being a frontline health worker. So, I think proper education will go a long way in stopping all these stigmas" . "It's due to ignorance; when you have professional colleagues and they are running away, they have fear, it is ignorance. When you have people that don't have medical knowledge; those ones can run away because of general fear" . "Lack of education; when people are not educated, they don't even know how to go about it, the implications and all that. So, they will stigmatize you because they feel you are carrying the virus on your body and you are coming to transmit it to them. If they are enlightened, trained and educated on that, both in the community and their working place, they will not stigmatize you" . "Lack of knowledge! Lack of knowledge! At first when the disease came, it was not well known, the knowledge was not vast. So, their ignorant in that aspect, if they have orientation, I think it will help a lot" . Some respondents stated that working at the isolation centre and public misinformation was one of the reasons for the stigmatization and narrated their feelings as follows. "It's simply because I am working with the corona patients and the disease is contagious, you can be infected through the air or through hand shake. All of these is what is responsible for the stigmatization" . " --- Theme five: recommendations Some recommendations made by respondents were public sensitization and improvement of services of FHCW . --- Subtheme: more knowledge on infection, prevention and control Education and awareness creation along with the observation of preventive measures were recommended by respondents as part of measures in curtailing the spread of the outbreak . Some of the respondents' narrations is as follows. "More education about the virus; creating awareness among the populace will help to reduce the stigma. Letting people know that the fact that someone is working in the isolation centre does not mean that he/she is having the virus all over their bodies. We need to educate people to understand that we are human beings and we need their support. If everybody runs away from us, it will be very traumatizing for us. We are doing something that is honourable and we expect the people to appreciate what we are doing and not to stigmatize us. I think with more understanding and more awareness education, the stigma will reduce" . "Education; in my own opinion I think that at some point in time, the information that was coming out was not synchronized because you have on one end government have an idea of what they want to do, but the end users; the message wasn't passed in the same magnitude, in the same perspective that it should. You find government say you need to use a face mask and the person says why should I use a facemask? Government will say using a facemask will protect you and the other person and the man will say that he doesn't want to protect himself. I think that a lot should have gone into educating and sensitizing people. I think that the religious bodies and a few key people should be making advocacy on what to do. Education was the real missing link. The method of message delivery did not come out in such a way that people could appreciate the magnitude of the problem that we are going through" . "Proper education of the population starting with the health worker; tell them that this disease is not just infectious because you work at the isolation centre, we wear complete PPE before attending to the patients and we ensure as much as possible not to get infected with the virus. So, proper education to accept everybody and even to see them as heroes instead of stigmatizing them will go a long way in solving it" . "Enlightenment, you need to enlighten the society on the disease, the mode of transmission and also to make them realize that in many situations someone has to take a bold step to contain the disease. Instead of being stigmatized, they should be praising us like it is done in a civilized society" . "The most important thing to do is regular hand washing, maintaining social distance, wearing of facemask and enlighten the community and the populace, let them know, that things are not the way they are thinking" . "There is need for health education, a lot of sensitization needs to be done everywhere; both to health personnel's and the communities. I think it is also important in the health sector, not only for frontline health workers but for everyone as long as you are in the hospital community. I think it is important for everybody to be trained, so that they can have understanding of the virus and can also be educating people out there. Let people have some basic knowledge about the virus. Community education and sensitization will go a long way, because if people have this understanding, I don't think there will be much stigmatization" . Subtheme: improvement of services of FHCW Some respondents expressed the need for more government involvement in the fight against the pandemic, motivation of FHCW and increase of manpower . "Motivation! Motivation! Motivation! Financial motivation, encouragement, honouring people. There are frontline health workers that are supposed to be honoured. Promotions and others as at when due" . "I know the management are doing their best but maybe they can increase the manpower, so that the time of exposure will not be much on me. if you are many, you know that you will just come and work once or twice and have your rest, you boost your immunity before you come back, that can help. If they can just give stipends as motivation" . "Everybody needs motivation but just like I told you, we have a wonderful team here; The Chief Medical Director of the Hospital, is also a member of the team, he is the General Officer, we have team lead, we have house manager, in fact, it's a pleasure working with this wonderful team and we need motivation" . "For the service, if there are some of the things we need that are supposed to be here which are not, some of the investigations which we need to do because the equipment are not there we couldn't do them but for the available ones, we are running them. We need the government to supply the needed equipment's in the laboratory so as to carry out other functions" . --- Discussion Findings of the e early stage of the pandemic revealed fear and anxiety based on the uncertainties of the outcome of events. This was also witnessed by various countries repatriating back their citizens. Other findings include; FHCWs rising up to the challenges of their duties and working wholeheartedly. Some of them emphasized their faith as their source of strength and courage. They expressed the need for emotional and financial support from the government; the government was lagging in their care. There was a call for the provision of laboratory equipment and improvement of their welfare package. Limited support by government can cause significant burnout and withdrawal among healthcare workers resulting in increased substance dependence behaviors, leading to considerable functional impairment [35]. Accepting the COVID-19 task to a great extent was expressed as a call to duty based on the specialty of the FHCW. They felt it was something they had to do. However, this was not without initial fear and anxiety as stated by some of the respondents. Working with the COVID-19 patients have been characterized as being stressful due to the possibility of being infected and the prolonged use of PPE when attending to the patients. Despite that, majority of the FHCW expressed their excitement with regards to patients' recovery and feeling fulfilled in carrying out their duties. A respondent, categorized patients into accommodating and understanding patients and those that are difficult to work with due to their perception that FHCW are performing their duties and they don't care if they infect them by omission or commission. Reports from China regarding the mental health of medical workers, state that health workers considered it difficult to deal with the dismayed, uncooperative, panic-stricken and stigmatized patients of COVID-19 which may result in apathy and withdrawal among clinicians [36]. Another issue raised by the FHCW was about patients finding it difficult to accept their test result within 12 to 24 h after they were brought to the isolation centre. This type of reaction "denial" is usually common with asymptomatic patients in a study [37] conducted in Lagos, Nigeria. The COVID-19 task was viewed by majority of the FHCW as an opportunity to serve humanity and the nation. There was also the feeling of fulfilment by these workers in carrying out their tasks. Some of the negative impressions observed by the respondents in carrying out their duties was the issue of stigmatization. Some felt their job was a professional hazard with the possibility of being infected and transferring the infection to their immediate families. Some regarded the task as enormous due to limited staff working at the isolation centre. Proper psychological well-being of the health care personnel's in this vulnerable time is absolutely essential [38]. Some FHCW felt that working at the isolation centre has not affected their line of duty in any way while others admitted a great difference from the duties they were carrying out in their various departments before being posted to work at the isolation by the hospital management. These changes were expressed as increased work load making the work more stressful, long duration of wearing of PPE, feeling discouraged due to their colleagues becoming infected and the possibility of them becoming infected. Study by Maunder et al. [35] indicates that caring for fellow ill colleagues during the pandemic may increase anxiety of health workers regarding their competence and skills, making them more vulnerable mentally. Globally, health care workers are increasingly battling against stigmatization and aggression against them [39]. Our findings revealed all respondents felt stigmatized while carrying out their duties; the stigmatization was mostly from their colleagues who were not part of those working at the isolation centre. Stigmatization was also expressed by some of their family members and the communities they lived in. Previous pandemics such as Severe Acute Respiratory Syndrome also reported stigmatization of healthcare providers working with SARS-affected patients [40]. Stigmatization of FHCWs in this study is related to the fact that this category of people is at high risk of being infected since they are directly involved with the treatment and care of people recovering from COVID-19 infection. Less stigmatization by the community was observed because most of the respondents stated that the community was not aware of where they worked. A FHCW was sent away from the community he was living in because the community leader came to know that he was working at the isolation centre. Several reports of eviction due to stigmatization of health care workers have been documented during the course of the ongoing COVID-19 pandemic [39,41,42]. Our findings on the effects of stigmatization includes psychological trauma, feeling withdrawn and rejection by the public. The withdrawal of these FHCW was to avoid being stigmatized and embarrassed in public while the rejection resulted in severing of relationships with family and friends. Potential drivers of stigma and aggression towards health care workers are the spread of misinformation and rumours through the mass media and social media. Hence, promoting fear, confusion, and ostracizing of health care workers in a frantic attempt by the public to stay safe [39]. Health care workers are targeted because they are seen as COVID-19 carriers [39]. A study in Singapore revealed fear, uncertainty, stigma with associated psychological distress among some of the primary healthcare providers caused by SARS [40]. Stigmatization towards healthcare workers adds to the physical and mental exhaustion that they bear in due course of their duty hours [43]. Common stigmatizing behaviours include isolation within residential communities, local stores, as well as among friends and relatives [44] as expressed by respondents in this study. Mental challenges mentioned were psychological trauma in the form of feeling frustrated and neglected, feeling demoralized due to stigmatization by family, friends and colleagues. Others include reduced contact with family, depression due to colleagues becoming infected without healthcare insurance in place to take care of them, the fear of possible infection anytime they had body aches or other symptoms, not being able to visit their families at the initial stage of the pandemic and the fear of losing friends. Exposure to people recovering from COVID-19 in hospitals, being quarantined, the death or illness of a relative or friend from COVID-19, and heightened self-perception of danger by the lethality of the virus can all negatively impact the mental well-being of health workers [45,46]. Separation of health care personnel from family during an infectious disease outbreak may result in enormous emotional toll on them whereas those that perform hospital duties and have to return home every day are at increased risk of developing anxiety with regards to the fear of transmitting the disease to their family members [47]. Also, clinicians may develop a sense of vulnerability due to a lack of definitive therapy, preventive vaccines, uncertain incubation period of the virus and the possibility of asymptomatic transmission [47]. This study revealed that there is no health care insurance for all the FHCW working at the isolation centre. Our finding calls for the urgent attention of the government to provide health care insurance not just for those FHCW working at the isolation centre but for all the FHCW at the forefront of this pandemic. Reasons for the stigmatization were fear of being infected, limited knowledge of the virus, misinformation of the public and working at the isolation centre. Previous studies have discussed an intense and wide spectrum of psychosocial ramifications that pandemics can inflict on the general population. The mass fear of COVID-19 "corona phobia" [48] due to the unpredictable course of the disease, intolerance of uncertainty, perceived risk of acquiring the infection can generate negative psychological responses including maladaptive behaviors, emotional distress and avoidance reaction among common people [49]. During disease outbreaks, news of the first death, acceleration in number of new cases and expansive media attention can heighten people's fears, frustrations, helplessness and anxiety over the situation. This results in misplaced health-protective and help seeking behaviors by anxious public that may lead to conflicts between clinicians and patients, which can be harmful to epidemic control programs and hamper social stability [48,50,51]. The FHCW need to be appreciated, supported and accepted in their battle against the COVID-19 pandemic. Stipulated recommendations were education and awareness creation which could be achieved through active engagement of community leaders, social media and other media platforms and religious leaders due to the vital roles they play in the society Others include training of the HCW on COVID-19 IPC, motivation of FHCW by improving their welfare package and recognition of their service to humanity through award presentations. Changing the method of evacuation of people that tested positive to COVID-19 from their homes in order to reduce the stigmatization; this is in coherence with a study [14] on FHCW recovering from COVD-19 infection conducted in Lagos State, Nigeria. People that tested positive to COVID-19 are usually evacuated from their homes using ambulance that has the tag of COVID-19 on it and people in the vicinity usually [14] stigmatize those that test positive to corona virus including their family members. This form of evacuation along with the community testing procedure and the accompanying stigma prevent people from health seeking behaviours. Some respondents suggested faith in God as a means of hope in the face of the pandemic. The limitation of this study is that the study was conducted in an isolation centre in Abuja, perhaps, there could be varying experiences in other isolation centres in Abuja or elsewhere within the country. --- Conclusion The study demonstrates the positive and negative experiences of FHCW. Frontline health care workers were stigmatized, psychologically traumatized and are battling to put in their best in the face of the pandemic. There is a need for the government and society to acknowledge and appreciate the efforts of FHCW. There is need to provide health care insurance for FHCW. Public education and sensitization on infection, prevention and control measures for COVID-19 would be relevant to address stigmatization in the society. In addition, adequate mobilization and engagement of community stakeholders such as traditional and religious leaders, and opinion group leaders should be prioritized in ensuring that FHCW do not suffer stigmatization while providing care at COVID-19 isolation centers. --- --- --- --- Competing interests The authors declare that they have no competing interests. ---

The COVID-19 pandemic has had a great toll on global health. Frontline healthcare workers (FHCW) directly involved in the treatment of COVID-19 patients have faced some physical and psychological challenges. This study explored the stigma and traumatic experiences of the FHCW during the COVID-19 pandemic in Nigeria. Methods: We recruited twenty FHCW directly involved in the treatment of COVID-19 patients through purposive and snowball sampling techniques. Face-to-face in-depth interviews were conducted for all participants, and qualitative analysis of data was done using Colaizzi's phenomenological method. Results: Five themes identified were: Early stage of the pandemic (fear, anxiety, public fright, other countries repatriating their citizens, the socio-economic impact of the pandemic and a call to duty for the FHCW); working with COVID-19 patients (excitement on patients recovery and duty stress); psychological, mental and emotional trauma; stigmatization (stigmatized by colleagues, family, friends or their residential communities, reasons for stigmatization which were fear of infection, limited knowledge of the virus and working at the isolation centre and the effect of stigma); and recommendations (education and awareness creation, government showing more care towards the FHCW and provision of health insurance for FHCW to take care of those that get infected in the line of duty). Conclusion: Stigmatization has proven to be a major challenge for FHCW in conducting their duties. The psychological impact experienced by FHCW may affect the quality of the services rendered by these workers. The study reveals the need of education and awareness creation in the ongoing pandemic. There is a need for the government and society to acknowledge and appreciate the efforts of FHCW.

INTRODUCTION Studies repeatedly demonstrate a protective effect of one's own educational attainment on dementia risk. [1][2][3] One hypothesised pathways linking one's own education and dementia risk include physiological changes in the brain that protect against dementia onset . Another possible pathway that may occur concurrently is by education influencing the socioeconomic trajectory of individuals providing exposure to protective factor such as higher income, better access to high quality medical care and cognitively demanding occupations. Marital status is also associated with dementia risk such that married individuals are at lower risk of dementia than their single or widowed counterparts. 4 Spousal education can provide resources at the household level that improve health outcomes for all members. For example, spousal education is inversely associated with mortality 5 6 and positively associated with self-rated health, 7 8 and marital status --- Strengths and limitations of this study ► This is the first study to evaluate the contributions of spousal educational attainment on dementia risk and allows its effect to vary by participant's own educational attainment, gender and race/ethnicity. ► This study follows a diverse sample of over 8800 individuals reporting own and spousal education in 1964-1973 and follows them for dementia between 1996 and 2017. ► This study adjusts for a range of health indicators prospectively collected from midlife and late-life. ► Limitations include being unable to control for duration of marriage, quality of education and childhood socioeconomic status. ► Lack of imaging data restricted the ability to examine the association between participant's own education or spousal education and markers of cognitive reserve. Open access is associated with access to healthcare. 9 10 Yet it remains unknown how spousal education or household level of education is associated with dementia risk. No prior studies have examined the association between spousal education and dementia risk and the two studies examining its association with cognitive function had opposing results. 11 12 Furthermore, it is unknown if and how one's own education, gender and race/ethnicity modify the relationship between spousal education and own dementia risk. Educational opportunities in the USA have historically varied by gender 13 and race/ethnicity. [14][15][16][17][18] The resources substitution theory 19 suggests that, in the US, women and minorities would benefit more from spousal education than White men since there are barriers to them accessing education and alternative health promoting resources themselves. On the other hand, the resource multiplication theory 2 suggests that White men in the US would benefit most from spousal education since they have more resources that augment the advantage provided by spousal education. This study aims to examine the association between spousal pairs' education levels and dementia risk in a diverse cohort of over 8800 men and women who reported their own and their spouse's educational attainment. We examined the association between participants' own education, their spouse's education and education concordance within spousal pairs with dementia risk. We hypothesised that one's own education and that spousal education were inversely associated with dementia risk independent of each other. We hypothesised that resource substitution would occur and the association between spousal education and participant dementia risk would be larger among individuals with less than college degrees, and for women and minority groups that have historically had fewer educational opportunities. --- METHODS --- Study population Analyses followed members of Kaiser Permanente Northern California who participated in the Multiphasic Health Checkups during the 1960s-1970s between the ages of 40 and 55 years and were KPNC members as of 1 January 1996. KPNC is an integrated healthcare delivery system. The member population is generally representative of the catchment area, with the caveat that individuals at extreme tails of the income distribution are under-represented. [20][21][22] The MHC was an optional check-up provided to health plan members in San Francisco and Oakland, California. A total of 14 696 individuals were married, 40-55 years old and reported their own sex and educational attainment, and their spouse's educational attainment at their MHC visit in the 1960s-1970s. We excluded 5861 people due to death prior to 1996 or lack of KPNC membership in 1996. Our final analytic dataset for the main analyses included 8835 members who were married and reported their own and their spouse's level of education. --- Patient and public involvement No patient involved. --- Participant and spousal education The 1964-1973 MHC questionnaire captured information on participant and spousal educational attainment. In separate items, participants were asked the highest grade they and their spouse completed . Participant and spousal educational attainment were recoded into four indicator variables as well as a binary variable with college completion as the threshold . High education was defined as at least completing a college. Educational concordance was classified as neither spouse completed college , participant did not completed college but spouse did , participant completed college but spouse did not and both spouses completed college . --- Dementia diagnosis Dementia cases between 1 January 1996 and 30 September 2017 were identified using KPNC electronic medical records, consistent with prior studies in this population. [23][24][25][26] The following International Classification of Diseases, Ninth Revision and Tenth Revision diagnosis codes were used to identify dementia cases: Alzheimer's disease , vascular dementia and other/non-specific dementia . A similar set of ICD-9 codes has been shown to have a sensitivity of 77% and a specificity of 95% compared with a consensus diagnosis of dementia using medical records review, physical examination, structured interviews and a neuropsychiatric battery. 27 Covariates Demographics obtained from KPNC records include age, race/ethnicity and gender. Health indicators from midlife and late-life were obtained from the MHC and KPNC medical records and may serve as mediators of the association between spousal education and dementia risk. The 1964-1973 MHC visit included clinical measures of blood pressure and self-reported current smoking status. Blood pressure thresholds were based on recommendations from the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure . 28 Individuals were classified as hypertensive if they had diastolic blood pressure ≥90 mm Hg or systolic blood Open access pressure ≥140 mm Hg. Midlife smoking status was classified as current, prior or never smoker. Late-life stroke or diabetes occurring before dementia were abstracted from electronic medical records between 1 January 1996 and 1 January 1997. Missing indicators were created for individuals who were missing information related to hypertension or smoking status. --- Analyses The distributions of demographics, participant education, spousal education, education concordance and participant's lifecourse health indicators were examined overall and by participant's gender. To mitigate bias due to possible selective attrition between the MHC and the start of dementia follow-up in 1996, we implemented unstabilised inverse probability weights of participation truncated at the 98th percentile that were the product of weights for survival until 1996 and membership in KPNC in 1996. Possible predictors of survival and membership were obtained from participants' MHC visit and included age , participant's education , spousal education , sex , race/ethnicity , midlife hypertension status and smoking status . To allow for the association between participant and spousal education and survival until 1996 to vary by gender and race/ ethnicity, weights were estimated separately for combination of race/ethnicity and gender. There was insufficient variability among individuals who survived to 1996 to model probability of KPNC membership in 1996 by gender and race, thus those weights were estimated among a pooled sample. Assuming no unmeasured confounding, implementing these weights accounts for differential survival until 1996, and KPNC membership in 1996. We calculated the standardised mean differences of age at MHC, participant education , spousal education , sex, race/ethnicity, midlife hypertension and midlife smoking status. The standardised mean differences were well below the threshold of <0.25, which may be used to represent adequate covariate balance . 29 We used sets of weighted Cox proportional hazards models with age as the timescale to examine the associations of participant's educational attainment, spouse's educational attainment and spousal educational concordance with dementia risk. Individuals were followed until the first of the following occurred: death, dementia diagnosis, a lapse in KPNC membership greater than 93 days or end of study period . All models also adjusted for gender and race/ethnicity. First, we estimated the association between participant's education as a four-categories and dementia risk. Second, we estimated the association of spousal education as a four-categories and dementia risk. Third, we included participant's education and spousal education, each as four categories, in the same model. Fourth, we included participant's education and spousal education, each as four categories, in the same model with further adjustment for participant's lifecourse health indicators , which are conceptualised as possible mediators. These analyses were then replicated with the binary version of participant and spousal education. Finally, we evaluated associations between spousal education concordance and dementia risk, with and without adjusting for participant's lifecourse health indicators. Possible differences in the association between participant educational attainment, spousal educational attainment and dementia risk by gender and race/ethnicity were examined in weighted models stratified by gender or race/ethnicity. Possible effect modification by gender and race/ethnicity was also examined with interactions terms included in inverse probability weighted Cox proportional hazards models estimating the association between dementia risk and the exposure of interest, the possible modifier of interest and the interaction terms comprised of the exposure of interest and the modifier of interest . P values for interaction terms containing categorical versions of education variables or race/ethnicity were from joint tests and from χ 2 tests for binary versions of education or gender. Lastly, we replicated analyses examining the association between participant's and spousal education as a fourcategories and dementia risk, adjusting for demographics, in unweighted Cox proportional hazards models. --- RESULTS The sample was 54.4% women, 36.5% non-white, with a mean age of 47.8 years at the MHC and 12.7 years of follow-up between 1996 and 2017 . Overall 30.6% of participants and 28.5% of spouses completed college. In midlife, 42.2% of the sample reported never smoking and 41.8% reported hypertension. In late-life, 2.6% of the sample had a stroke and 11.4% had diabetes. Women were less likely than male participants to have at least a college degree , more likely to have a spouse with at least a college degree and less likely to be in a couple in which both members have at least a college degree . During follow-up , 30.4% of members received a dementia diagnosis. Women and minorities other than Asians were more likely to receive a dementia diagnosis then men (33 --- Open access the end of the study period , 19.1% of the members were alive, dementia-free and remained members of KPNC. --- Participant and spousal education operationalised separately as four indicator variables each In models separately examining participant and spousal educational attainment , there was evidence of dose-response associations such that more education for either the participant or the spouse predicted lower dementia risk for the participant . In models including both participant and spousal educational attainment , college degree and postgraduate education for participants were associated with lower risk of dementia compared with reporting high school education or less, but spousal Open access educational attainment was not associated with participant dementia risk. There was no difference in the effect of participant or spousal educational attainment on dementia risk by participant gender or participant race/ethnicity . There also was no difference in the effect of participant education on dementia risk by spousal educational attainment . --- Participant and spousal education operationalised separately as binary variables Examining participant and spousal high educational attainment separately, participant high education or spouse high education was associated with lower dementia risk in participants adjusting for demographics . Examined concurrently, participants obtaining high education continued to be associated with lower dementia risk but the estimated effect of spousal high education was attenuated . Effect estimates remained similar after further adjustment for midlife and late-life health indicators . Though effect estimates for the association between participant and spousal college degree on dementia risk varied by gender and race/ethnicity , these differences were not significant . There also was no difference in the effect of participant education on dementia risk by spousal educational attainment . --- Concordance between participant and spousal education In demographic-adjusted models examining education concordance, with participants in couples where neither spouse completed college as the reference, participants in couples where both spouses completed college had 30% lower risk of dementia . Participants in couples where the participant had completed college but the spouse had not had 17% lower risk of dementia , while participants in couples in which the participant had not completed college but the spouse had did not have any protection from dementia . Among participants who had completed college, participants with spouses who also had completed college were at lower risk of dementia . Effect estimates were slightly attenuated after further adjustment --- Open access for midlife and late-life health indicators and there was no additional benefit of spousal college degree among participants who completed college . Though effect estimates for the different categories of education concordance varied by participant gender and race/ethnicity , the differences in effect by gender or race/ethnicity were not significant . Unweighted models: participant and spousal education operationalised separately as four indicator variables each As in weighted models, in unweighted models separately examining participant and spousal educational attainment, there was an inverse dose-response association between both participant and spousal education and dementia risk . In unweighted models including both participant and spousal educational attainment , participants college degree and postgraduate education was associated with lower participant dementia risk, but spousal educational attainment was not associated with participant dementia risk. --- DISCUSSION In a large, diverse, longitudinal study, we found that higher levels of participant's own education were associated with lower dementia risk regardless of spousal education, demographics and health indicators. An inverse association between spousal education and dementia risk was also present independent of participant demographics, however, the effects became non-significant after adjusting for participant education. Contrary to our hypotheses based on the resource substitution, we did not find evidence that the effect of spousal education was modified by participant's education, gender or race/ethnicity. Though effect estimates varied somewhat by gender and race/ethnicity, none of the differences in estimated effects were statistically significantly. Though prior research has not examined the association between education concordance and dementia risk, our findings are consistent with a prior study demonstrating a protective effect of spousal education on late-life cognitive outcomes. 11 A study using data from 5846 men and women participating in the Health and Retirement Study, a nationally representative study of non-institutionalised US adults at least age 50 and their spouses, found that greater years of spousal education were associated with higher respondent cognitive level at age 65 as well as a slower rate of cognitive decline over an 18-year period. 11 The association between spousal education and respondent cognitive decline persisted after adjustment for markers of adult socioeconomic status , but the association between cognitive level at age 65 and spousal education was attenuated after adjustment for these potential mediators. There was no evidence of effect modification of the relationship between spousal education and late-life cognitive outcome by gender. On the other hand, in a study of 19 319 female nurses at least 70 years old, husband's education was not associated with participant's risk of being in the bottom 10th percentile of baseline global cognition adjusting for women's age and own education. 12 Similarly, husband's education was not associated with whether a woman Open access experienced substantial cognitive decline during the 2-year follow-up period. If causal, higher spousal education may reduce dementia risk through higher levels of household resources , cognitive stimulation derived from spouse's education or better health behaviours related to cardiometabolic health. For example, having a more educated spouse has been associated with higher levels of physical activity 30 and inversely associated with smoking. 7 Both low income 31 and poor cardiometabolic health indicators 24 25 32-34 have been associated with greater dementia risk. However, adjusting for midlife blood pressure and smoking, and late-life diabetes and stroke did not change the relationship between spousal education concordance and dementia risk. Overall, these findings show that one's own education is more relevant than one's spouse's education for lower dementia risk. This is consistent with education primarily protecting against dementia risk through physiological changes in the brain that protect against dementia onset such as increased number of synapses, brain size and redundant neuronal networks. 35 Individuals with high educational attainment would have greater cognitive reserve and therefore would present with fewer clinical signs of dementia than their counterparts with low cognitive reserve with the same amount of pathology. 36 For example, among individuals with similar severity of clinical symptoms of Alzheimer's disease, those participants with high levels of education had more severe reductions in regional cerebral blood flow, reflecting greater Alzheimer's disease pathology, than those with lower levels of education. 37 To our knowledge this is the first study to investigate the association between spousal education, spousal education concordance and dementia risk. These analyses accounted for differential selection into our analytic sample by implementing inverse probably weights estimated within sex and race/ethnicity specific groups. However, the possibility of residual selection bias remains if there are additional predictors of survival and KPNC membership in 1996 that are associated with dementia risk. High membership stability in this diverse cohort allows us to adjust for a range of covariates prospectively during midlife to late-life. Some limitations include being unable to control for duration of marriage and quality of education, which has been shown to better predict cognitive decline than years of formal education. 38 This may be particularly pertinent for gender differences in college education, if men and women in these generations systematically pursued different training in college. We were unable to identify spousal pairs in which both spouses are included as participants in this study and therefore cannot account for interdependence of these observations. Lack of imaging data restricted our ability to examine the association between participant's education, spousal education and education concordance with markers of cognitive reserve. Unmeasured confounding could contribute to observed associations. We may have been underpowered to detect differences by race/ethnicity and gender, thus confirming our results in large, diverse, independent data sets is critical. There may be undiagnosed cases of dementia. Assuming spousal education is inversely associated with participant dementia risk, the associations between spousal education and participant dementia risk would be underestimated if undiagnosed dementia were more common among participants with married to spouses with lower levels of education. It is unclear whether these results are generalisable to individuals who were born during a different time periods since there are secular trends in education obtainment and quality. Our findings build on prior work examining the association between one's own education and dementia risk by including spousal education and allowing the effect of spousal education to vary by one's own education, gender or race/ethnicity. Our findings suggest that one's own educational attainment is more relevant to dementia risk than spousal educational attainment. Additional research is needed examining the association between spousal education and one's own dementia risk and, if causal, should consider possible physiological, behavioural and socioeconomic mediators of the relationship. --- Competing interests None declared. Patient consent for publication Not required. --- Ethics approval

Objective The role of spousal education on dementia risk and how it may differ by gender or race/ethnicity is unknown. This study examines the association between one's own education separate from and in conjunction with spousal education and risk of dementia. Design Cohort. Setting Kaiser Permanente Northern California (KPNC), an integrated health care delivery system. Participants 8835 members of KPNC who were aged 40-55, married and reported own and spousal education in 1964-1973. Primary outcome measure Dementia cases were identified through medical records from 1 January 1996 to 30 September 2017. Methods Own and spousal education was self-reported in 1964-1973 and each was classified as four indicator variables (≤high school, trade school/some college, college degree and postgraduate) and as ≥college degree versus <college degree. Age as timescale weighted Cox proportional hazard models adjusted for demographics and health indicators evaluated associations between participant education, spousal education and dementia risk overall and by gender and race/ethnicity. Results The cohort was 37% non-white, 46% men and 30% were diagnosed with dementia during followup from 1996 to 2017 (mean follow-up=12.7 years). Greater participant education was associated with lower dementia risk independent of spousal education, demographics and health indicators. Greater spousal education was associated with lower dementia adjusting for demographics but became non-significant after further adjustment for participant education. The same pattern was seen for spousal education ≥college degree (not adjusting for participant education HR spousal education≥college degree =0.83 (95% CI: 0.76 to 0.90); adjusting for participant education HR spousal education≥college degree =0.92 (95% CI: 0.83 to 1.01)). These associations did not vary by gender or race/ ethnicity. Conclusion In a large diverse cohort, we found that higher levels of participant's own education were associated with lower dementia risk regardless of spousal education. An inverse association between spousal education and dementia risk was also present, however, the effects became non-significant after adjusting for participant education.

Paleru play story revolves around protagonist Venkanna. He works at an aristocrat, suffers a lot. Later he overcomes all his odds and studies very well. At the end of the play , he gets a job, stops the injustice. Palleru play inspired many people. His Raga Vasistam is a special one, it propagated Indians are Aryans. In Raga Vasistam play Arundhati, Vasisthudu, prachinudu, sandhya characters are popular ones. Bhimanna dreamt egalitarian society. In this paper I would like to bring out dichotomy of the upper caste and lower caste people which was existing in India. It became a major problem in rural India. In India various traditions, caste, religions are there. Our old rulers allowed the different races from alien nations. Indians feel unity in diversity, but in implementation way it has become a failure. --- In his Author's Introduction to Three Plays , Girish Karnad clearly stated: To my generation a hundred crowded years of urban theatre seemed to have left almost nothing to hang on to, or take off from. And where was one to begin again? Perhaps by looking at our audience again, by trying to understand what experience the audience expected to receive from the theatre."1 The meaning of "Dalit" in Oxford Advanced Learner's Dictionary runs thus:"in the traditional caste system a member of the caste that is considered the lowest and that has the fewest advantages: the dalits struggle for social and economic rights." Drama is an aspect, which transforms the lives of the people. In modern Telugu, Kanada Drama's sky Padma Bhushan Bohie bhimanna, Gnanapita recipient Girish Karnad are like sun and moon. If we divide their plays according to genre,these are categorized as traditional plays, Historical ,social ones. In Telugu language Bhimanna wrote Palleru,Cooli Raju, Pairu pata, Padipothuna Addugodalu, Manavuni Maro Majili, Sneha sundari,etc.In Kanada literature Girish Karnad wrote Yayati, Tuglaq, Hayavadana, Taledanda, Bali, Naga mandla, Bimba, Agni varsh etc. In the plays of duo they portrayed social elements freely. In these two playwrights plays dalit aspect is visible in a crystal clear manner. In every line of their plays dalit perspectiveness is depicted.In palleru play Bohie bhimanna picturized about the atrocities of upper castes preventing the school education, and allowing the low caste people to do the drudgery in their fields in a well manner. In Taledanda play Karnad created Vijalla who belonged to lower clan. In 12 th century there was a great caste bifurcation. By portraying this character karnad brought equality among the human community. In all these duo's plays Dalit aspect is visible in direct and indirectly. Bhimanna "Raga Vasistam" is a socio fantasy play. Despite of the socio fantasy elements, this play highlights the oppression of Dalits , portrayed among the lovers,but in the end of the play,he concluded that God should come to the earth to eradicate caste disparity.Bohie Bhimanna wanted to convey the message in the character of Lord shiva,he brings some reformation in upper castes,Dalits development is emphasized at the conclusion of the play. In Agni Varsh play Karnad used socio-fantasy technique.Based on this technique ,he selected purana theme in a satirized manner through paravasu,Aravasu Brahmanna characters brought forth the oppression of upper castes. Through Nithili Girijan maid he proposed Dalit aspect in this play. Nithili was loved by upper castes. But at theend of the play a line conveys the atrocities which are incurred on the lower caste people. Nithili's lover Aravasu pronounces that "we should not believe upper caste people." In this way karnad portrayed the concealed dalit perspectiveness in this play. From good old days on wards India became hub of caste system. Hindu traditions developed this system. Hindu epics, literature ,arts propounded this theory and imparted into the minds of Indians. It spread like a wild fire. Due to this maladies un touchability was formed, untouchable community led their lives in the vicinity of darkness. Bhimanna's plays reemphasized the maladay and brought some change in the society. His contribution to the telugu drama,is an immense one and wanted to spread sarvodaya socialism. Karnad highlighted the same aspect in his plays. Tale -Danda depicts the violent history of an anti caste movement in the 12 th century Karnataka as a parallel of the Mandir and mandal agitation of the late 1980s.It is based on the caste system in India. It reveals the majority religion turning against itself. He highlights the conflicts not only across caste boundaries within Hinduism but also between Hinduism and reformist religions like Buddhism and Jainism. In Tale Danda , Karnad deals with one of the most sensitive issues of all times-the ugly face of caste system of India that was in the past hailed an ideal one. Though the play is based on an historical event, Karnad's adept use of symbolism, irony and humour makes it a modern play. It is because of these modern devices that situations and the minor characters in the play dramatize the contemporary socio-political scenario in India.4 In the play, Tale-Danda is a clash between the traditional orthodox minded people and the people of progressive views like Basavanna who want to establish a society based secular philosophy. Bijalla is all the time aware of his origin as he himself comes from barber community. Through Bijjala, Karnad comments on caste system in India. Basavanna believes in the philosophy of non-violence and he dislikes the treatment given by his followers to the Jains. Karnad contrasts the life of discipline and sacrifice with the life of instinct and emotion through the character of Nittilai. The play associates Brahmanism and ruthless and shudra culture with love, compassion , freshness, and hope although the contrast is not simplistic or absolute. The character of Nittilai is introduced to show how caste boundaries oppress people.It dramatically presents the conflict between good and evil.The images of love finding its own world and casting aside the world torn apart by jealousy,communal "Jathi Anede Manishi pi charmamulantidi. Danni valachi paresina kotha charmani chusi kuda andaru patha jathine gurthu thechukuntaru.Vedu Mala,Vedu Khsatriya,Vedu Golla vadu." In this way Bhimanna ,Karnad's plays propelled the theory of dalit perspectiveness. Karnad's Taledanda only depicts the dalits problems,but bhimanna picturised dalit problems in all his plays. By using the characters Jaggadeva Malli Bomma,Basavana Bijalla,Harallaiah,Madhu varasa, karnad propagated the dalit theory in Taledanda play. All these characters have amicability in this play. In paleru play Bhimanna venkanna, upakari, Ramam,Ramadevi,Umadevi, Param Jyothi,Madhu characters revealed not only dalit aspect, there should not be any disparity between any religion,caste.Both rendered their service to create egalitarian society. Both the writers depicted the Indian caste system and life of untouchables in their works in order that they might awaken readers to their own social evils and the atrocities and help to bring about a social revolution. "Karnad himself tells that he had the "Mandal" and "Mandir movements and the unrest they generated at the back of his mind when he wrote the play, Tale Danda is a fast moving play with exciting action; it is a pity it could not be something more."5 Humanism is at the centre of Karnad's fictional art. His humanistic vision is variously drawn from the east and west. Compassion is the compelling motive in his humanist vision. It is essentially the love of humanity for its own sake and in all its unfailing faith in its nobility. Man is essentially perfect. His imperfect nature, if any, is due to environment, and other factors. Human creativity is always and unquestioningly towards realizing positive and fruitful levels of existence. Humanism is better than religion. If the human mind-set changes , a better society and a better tomorrow can be expected and established.

Girish Karnad , a genius, one of the most prominent English play-wrights. Bohie Bhimanna hails from Andhra Pradesh. Karnad from Karnataka, while both writers exposed contemporary social and political issues in their plays. They highlighted the darker aspects of life so as to revolutionize and reform the men and manners of the people. Both writers tried to voice the hardships, emotions, and feelings of the poor, down trodden and subjugated people in their works.

Introduction Early initiation of substance use during adolescence is a salient predictor of Substance Use Disorders later in life [1] [2] [3] [4]. Thus, delaying the age of initiation is one of the major goals of prevention programs targeting the young. There are risk factors and protective factors that influence age of initiation [3] [5] [6] but there is no clear blueprint on how to prioritize actions targeted at diminishing RF and enhancing PF. One salient issue, empirically understudied in the literature, is the complex interdependence between RF and PF as they influence target behavior such as age of initiation. It is acknowledged that the interplay between RF and PF is highly relevant to explain specific behavioral patterns [7]. Jones, Hill, Epstein, Lee, Hawkins & Catalano [8] pointed out the Social Development Model and developmental cascades framework as valid theoretical foundations based on which to understand the interrelation of RF and PF holistically. Similarly, ecodevelopental theory promotes the integration of RF and PF to uncover multiple determinants of substance use initiation among young adolescents [9]. However, the common approach reported in the literature to analyze the influence of RF and PF on relevant behaviors consists of conducting different types of multivariate regression analyses, and using the size of regression coefficients as an indicator of the power of RF and PF to influence the target variable . Usually, the size of regression coefficients captures the effect of each independent factor when other factors are held constant at their average. That is, they show the "isolated" effect of each factor. Some statistical interactions are frequently reported but to our knowledge, there is no account of empirical work looking at the combined interactive effects of multiple RF and PF. In addition, most regression models are based on the assumption of linear relationships between independent and dependent variables, which is arguably an oversimplification of the complex links among RF and PF. Consequently, given the interdependent nature of RF and PF and the potential nonlinearity of their linkages, multivariate regressions may be offering an inexact blueprint of how to prioritize RF and PF in interventions targeted at reducing age of initiation. In this paper we tackle this issue by means of a different analytical approach. We examine a multivariate interdependence technique as an alternative way to answer how to prioritize RF and PF in order to influence age of initiation. MCA is able to capture multiple associations among interdependent factors without making assumptions about functional forms [10]. We include RFs and PFs at the social, community, and family level. We compare our results with that of multiple regression models for the same data and discuss the differences and derived implications. In short, we find that the two statistical approaches indicate a different order of associations between RF, PF and early initiation. --- Early initiation of drug use as a predictor of later adolescent and adult drug use disorders Using drugs and alcohol at an early age has been associated with multiple problems later in life such as negative health, social, and behavioral outcomes [11] [12]. Kessler et al. [13] have suggested that age of onset should be a major focus of study because it explains the risk of a disorder in the future. There are an extensive number of studies that show that initiation of substance consumption early in life influences the levels of use and abuse in later life as well as alcohol abuse disorders. For example, DeWitt et al. [5] reported that the likelihood of developing lifetime alcohol dependence increases with each year of alcohol use onset age. Liang and Chikritzhs [14] found associations between early onset age and later heavy drinking; the authors suggest that this happens because the earlier the age of onset, the longer the time at risk for alcohol consumption to escalate until it becomes a problem. In addition, early substance initiation has been identified as an RF for injection drug use [6], binge drinking [15], hazardous levels of alcohol consumption and drug use [16]. Epidemiological studies found evidence of higher alcohol dependence rates for individuals that initiated alcohol use by age 14, than those who started at 20 or older, as well as illicit drug dependence or abuse for those who first tried marijuana at age 14 or younger [3]. Early-onset cocaine users have also shown neuropsychological alterations and higher polydrug use, than those with a late-onset [17]. Early cannabis use has been associated with other drug use and substance use disorders. The prevalence of drug abuse symptoms in adulthood decreased with later age of cannabis use onset. Rioux, Castellanos-Ryan, Parent, Vitaro, Tremblay and Se ´guin [18] found a difference of 30% in the presence of these symptoms between those who started at 13 years or earlier and those who started using cannabis at 17 years when they were 28. --- Risk and protective factors associated with age of initiation Despite the relevance of early initiation, scarce evidence is available about its causes. According to Kaplow, Curran and Dodge [19], it is relevant to identify whether the early onset of drug use and the eventual substance abuse involve the same associated factors. A small number of studies have explored specific RF and PF associated with early engagement with drugs. As such, Malmberg, Overbeek, Monshouwer, Lammers, Vollebergh and Engels [20] found associations between early adolescence symptoms of anxiety, hopelessness, sensation seeking and impulsivity, and lifetime prevalence and age of onset for different drugs. Moreover, Kaplow et al. [19] identified that during childhood, personal factors such as overactivity, thought problems and problem solving skills, and parental substance abuse contributed to early initiation of drug use. In this line, a recent study from Maggs, Staff, Patrick and Wray-Lake [21] pointed out that personal and parental factors, such as parent lack of control of children's behavior and parent substance use are specific predictors of early initiation of alcohol consumption. A study conducted with Indigenous youth from the US and Canada revealed that positive representations of the prototypical adolescent drinker and having peers who drink increases the risk for the onset of alcohol use [22]. Aggressive behavior, gender, and father's educational level have also been identified as predictors of early alcohol use [23]. Initiating sipping or tasting alcohol was predicted by perceived parental approval and by current parental drinking status, influencing attitudes toward this behavior [24]. A family history of alcohol problems has also been associated with initiating drinking [25] [16] and its effect is stronger before the age of 15. Other studies have explored the contributions of broader domains on early substance initiation. For example, Burlew, Johnson, Flowers, Peteet, Griffith-Henry and Buchanan [26] identified among African American youth that living in a community characterized by high levels of substance use, violence and poverty increases the risk for the early onset of drug use. Also, promotional alcohol items encourage alcohol initiation [11]. Enstad, Pedersen, Nilsen and von Soest [27] assessed personal, social, economic and family dimensions to identify specific predictors for early onset of intoxication compared to early onset of drinking behavior. This study involving Norwegian adolescents showed that temperament, norm-breaking behavior, socioeconomic features, and family factors predicted early onset of intoxication, while low levels of shyness and high friend deviancy were associated with early onset of drinking. PF associated with substance use age of onset has also been explored in previous studies. However, less evidence is found in this regard. In a sample of Mexican youngsters, Atherton, Conger, Ferrer and Robins [28] found that close families with strong values show a decreased risk of early engagement with drugs. Ryan, Jorm and Lubman [29] argued that delayed alcohol initiation was predicted by parental drinking modeling, by limiting the access of alcohol to children, by quality parent-child relationships, and by parental involvement and communication. Parental monitoring and warmth are indirect antecedents of drug onset, as they predict adolescents' social perception of drug use [30]. Family attachment also indirectly increases the age of drug use onset as it lowers negative symptoms and sensation seeking in adolescents [31]. In addition, Bacio et al [9] argued that late initiation of drug use is an outcome of positive school climate, which lowers perceptions of norms of use between peers, reducing their likelihood of beginning substance use in early adolescence. There are also categories of PF that influence a wider range of drug related behaviors , including family, school and community, which are the focus of this work. In the family category, substance is reduced by family connectedness [32] [33], parental supervision [34], clear rules [35], positive parenting style [36], and living in a two-parent family [37]. At school and community levels, some factors that have been shown to lower the probability of drug use among adolescents are: positive climate at school, connection to school or other adults in the neighborhood, feeling safe at school or in the community, policies and practices that support health, norms, and opportunities in the community for meaningful engagement [36] [37]. This knowledge, however, falls short in explaining the interdependence of factors. Moreover, interdependence may alter the way in which each individual factor influences drug related behavior, among which early initiation stands out as critical in the prevention of later SUDs. Hence, we argue that understanding the interplay between RF and PF at all levels of adolescents' socialization is essential to developing well-targeted prevention strategies to delay the age of onset. The objective of this study is to contribute to that goal, by identifying the RFs and PFs that are more closely associated to early initiation, accounting for the interplay of social, community, and family factors. --- Method We analyzed the relationship between age of onset and RF and PF using cross-sectional data. We applied a survey to 1272 adolescents aged between 12 and 19. The mean age was 14.87 , and 56% were girls. The Research and Ethics Committee at Universidad de la Sabana approved the research procedures for data collection for this study in minute number 62, 2013. We used the Spanish version of the Communities That Care Youth Survey by Arthur, Hawkins, Pollard, Catalano and Baglioni [38]. Professionals trained in the application of the CTC-YS administered the electronic version of the survey at the schools. This electronic version was set up such that all questions had to be answered in order to allow participants to progress along the questionnaire. Hence, no missing data was generated. To guarantee confidentiality, we used codes for each participant. Electronic responses were recorded in an excel file and then exported for later statistical analyses. The CTC-YS test consists of 135 questions. It measures the level of exposure to both RF and PF related to the consumption of alcohol, cigarettes, marijuana, inhalants, and other substances. It also measures consumption patterns and antisocial behaviors among adolescent students in grades 6 to 12. RF and PF are measured at different levels: family, social, community, and personal characteristics and beliefs. We focused on factors grouped by a) Family: Opportunities and rewards for prosocial involvement in the family, family attachment , family conflict , family history of antisocial behavior , favorable attitude toward substance and poor family management ; b) Social dynamics: school perceived opportunities and rewards for prosocial involvement, low commitment to school and bad relations with peers ; and c) Community: laws and norms favorable to drug use , community disorganization , low neighborhood attachment , perceived availability of drugs , opportunities and rewards for community prosocial involvement. In total, 17 RF and PF were assessed by asking adolescents in a 4-point scale about their levels of exposure to both RF and PS related to substance use. In the CTC-YS, early initiation is measured using the following six items: How old were you when you first. . . smoked a cigarette, even just a puff; had more than a sip or two of beer, wine or hard liquor ; began drinking alcoholic beverages regularly, that is, at least once or twice a month; smoked marijuana; used inhalants ; the first time you got drunk. The survey was implemented by means of a collaboration effort with the municipalities of Cogua and Ubate ´, near Bogota. The study objectives were explained to schools in both municipalities. The schools that expressed interest in participating sent informed consents to the adolescents' parents or caregivers for them to be included in the sample. Adolescents whose parents signed the informed consent were asked to ascertain their participation by signing an assent consent. As explained earlier, we sought to evaluate the association between early initiation in drugs and the 17 RF and PF from a perspective that 1. Makes no assumption about the mathematical functional form of the relationships and 2. Incorporates the interdependent nature of RF and PF in the analysis. In order to do so, we chose to use a Multiple Correspondence Analysis as a statistical tool. This is an interdependence technique that establishes the association between categorical variables based on the mathematical distance between categories and objects within these categories [10] [39] [40]. It is a compositional technique that provides a low dimensional representation of the multiple associations of all possible twoway cross-tabulations of a set of categorical variables. The geometrical distance between categories and category levels is a standardized measure of association based on the conditional probability of observations of a category a, given another category b. Table 1 shows basic descriptive statistics for RF, PF, and early initiation. We first look at the distribution of each of the RF and PF constructs including the measure of early initiation. The composite measure of early initiation gives values from 0 to 7, where 0 is never, 1 = 17 years old and so on until 7 = 11 years old. Thus, the mean of 1.30 refers to an average age of between 16 and 17 years old. For the specific substances that constitute our measure, initiation of alcohol use was 3.70 ; of cigarettes, it was 1.14 ; and of marihuana, it was 0.32 . As it pertains to the other RFs and PFs, the CTC-YS uses four-level ordinal-categorical items to capture RFs and PFs that are later averaged to obtain a more nuanced, metric measure of each RF and PF . For the upcoming procedures and analyses, we use the Multiple Correspondence program embedded in SPSS v. 24. The first step in the implementation of the MCA analysis is to discretize the RF and PF measures in three categorical levels, based on the mean and standard deviation of each RP and PF. This step gives a clear qualitative interpretation of the different categorical levels. For instance, our target variable, early initiation, is discretized in the following way: early initiation = between 11 and 14 years old ; middle initiation = 15 and 16 years old ; and late initiation = over 17 years old or never . Adequate cut off points to categorize early initiation are variable in the literature and dependent on the substance studied, In this study, considering that our measure includes various substances, the categorization is consistent with previously used theoretical cut off points for early initiation . In all cases, we used a threelevel ordinal categorization for a straightforward interpretation of their meaning and association. We conducted the analysis with all 17 RF and PF plus early initiation using variable principal normalization. We produced several partial biplots to facilitate interpretation, considering that in MCA there is no definition of dependent and independent variables. All two-way cross-tabulations are processed simultaneously. --- Results To examine the relationship between RF and PF and early initiation, we focused the analysis on the relative position of the three early initiation categories vis-à-vis the 17 RF and PF. The two-dimension MCA can account for over 36% of the inertia, the first dimension accounts for 23% and the second for 13%, with each dimension displaying appropriate Cronbach's alphas . --- Data visualization Given the high number of variables in the analysis, we will produce several partial biplots in order to facilitate the visualization of results. All figures come from one single MCA analysis and therefore this partial visualization does not affect the estimated distances between category levels and the accounted inertia is the same for all figures. In Fig 1 we show the full biplot of the RF and PF categories. Early initiation is highlighted as the bold circle. The first result of this visualization is that all RF and PF categories show an expected overall pattern of monotonic relation with early initiation. That is, high risk and low protection categories are grouped closer to early initiation, while low risk and high protection categories are grouped closer to late initiation. The pattern is the same for all RF and PF. The strength of association among categories is given by their geometric proximity. We will now present partial plots with fewer categories to improve interpretation. The first is a comparison of RF factors and early initiation (Fig 2 --- ) against PF and early initiation . There is a noticeable difference between the two plots. RF and early initiation category clusters are better defined than those of PF and early initiation, particularly for early initiation. This means that the pattern of association between RF and early initiation is more homogenous across categories than that of PF and early initiation. This result is consistent with the literature on RF and PF, where the effects of RF are reported to be stronger and more pervasive. However, the direction of the categories of the PF categories cluster indicates that a potential cause of such a difference is a nonlinear relationship between most PF and early initiation. This can be seen in the shape of the cluster around early initiation. The general biplot can also be split by the dimension of RF and PF, namely family, social, and community. Figs 4, 5 and 6 contain the corresponding biplots. They show that the pattern of association is most homogeneous for both RF and PF related to the social dynamic in which the clusters around early, middle, and late early initiation are clearly separated from each other and their shape is rather rounded. The biplot for the family dimension is much less homogeneous , and once again the non-linearity is observed in the pattern of associations from middle to early initiation. Finally, the biplot for the community- --- The labels in the plot region next to each category indicate the range of values included in such category. For instance, the label next to a point in the plot means that such category point represents values from 0 to 1 the original scale of the corresponding RF or PF. Early initiation is the only variable that is plotted with a solid shape. Gender is represented by the letters F or M and Age is not discretized in the plot. It takes values from 11 to "19 or more". https://doi.org/10.1371/journal.pone.0225384.g001 related categories shows an even less linear relationship across all ordinal levels . The distances among RF, PF, and early initiation are differently distributed in each level. For some RF and PF, the level of early initiation they are most closely related to becomes visually unclear. The next step is to look at the specific distances from every RF and PF to early initiation. As explained earlier, the closer the geometrical distance, the closer the association. This analysis also reveals the strength of the non-linearity between RF, PF and early initiation levels by calculating the absolute value of the normalized distances between each RF and PF category and the corresponding early initiation level, using the normalized coordinates in each dimension: Total distance ¼ X 3 i¼1 j ðF id1 À EI id1 Þ þ ðF id2 À EI id2 Þj Eq 1 where Fs are the different RF and PF, d1 and d2 are dimension 1 and 2 of the biplot, and i, where i 2 {1, 2, 3} is each of the three ordinal categorical levels. for each RF and PF for each ordinal level and the total distance. If the three distances for each F are similar, this indicates linearity, if they vary it shows non-linearity. Table 3 is ordered from the most proximal to the most distal factors based on total distance. This means that RF and PF are ordered from the most closely associated to the least associated to early initiation. Considering that the biplot coordinates are calculated taking into account all two-way cross tabulations of every RF, and PF with each other, hence, the interdependence of factors is part of the results. These results would indicate that in the population and area that this sample represents, interventions should focus mostly on social dynamics and community, which are the top five most closely associated factors with early initiation. The family dimension RFs and PFs are the least associated. In particular, the top five associations are to 1) perceived availability of drugs , 2) laws and norms favorable to drug use , 3) rewards for prosocial involvement in the community , 4) negative relationships with peers at school , and 5) low commitment to school . The three least associated are 1) family attachment , 2) family history of antisocial behavior , and 3) opportunities for prosocial involvement in the family . It must be said that these conclusions are the outcome of the relative total of geometric distances. No effect sizes can be derived from this information. To assess these results and the ensuing recommendations for prioritizing interventions, we also conduct a traditional analysis using multiple linear regression with early initiation as the dependent variable and all the RFs and PFs plus age and gender as independent variables. We estimated the following regression model: EI ¼ b 0 þ X 18 i¼1 b i F P;R i þ b gender ðageÞ þ b gender ðgenderÞ þ ε where F P;R i 2 f18 RF; PFg Eq 2 The regression model was able to account for 26% of variance ; . In Table 4, we show the regression coefficients ordered by standardized betas to allow them to be compared. Effect sizes can be estimated using regression analysis, in this case using the standardized betas. They show that the five biggest effects are found for 1) parental positive attitudes towards drug use , 2) perceived availability of drugs , 3) family conflict , 4) family history of antisocial behavior , and 5) poor family management . The four smallest effects are found for 1) opportunities for prosocial involvement in the community , 2) negative relationships with peers at school , 3) laws and norms favorable to drug use , and 4) opportunities for prosocial involvement at school . In order to check the regression results for robustness, we also conducted an ordered logistic regression using the discretized variable of age of onset, as used in the MCA, and the same independent variables and covariates. Results were highly consistent with the linear regression. The ordered logistic regression details can be found in supplementary material S2. --- Discussion The National Institute of Alcohol Abuse and Alcoholism [41] affirms that prevention programs and public health policies should specifically target children under 15 and underage drinking, in general, in order to attempt to delay the onset of drinking alcohol as long as possible. The effects of early initiation on later life SUDs are very well documented. Moreover, debates about early initiation have important implications for the allocation of screening and prevention resources. Selected interventions during adolescence may benefit multiple domains including academic, peer relations, and delinquency [21]. For instance, knowledge about factors that delay early initiation has been essential in shaping alcohol prevention programs [27] [42]. This paper investigates the association between early initiation of substance use and RF and PF divided into family, social, and community categories. Our findings therefore contribute to prior theory and research that calls for a multiple factor, multiple domain perspective to advance the understanding of social and environmental influences on youth well-being and adaptation [43] [44][45] [46]. We used an approach that incorporates the interdependent nature of RF and PF and makes no assumptions about the functional form of the relationships. The statistical tool that serves such purpose is Multiple Correspondence Analysis. This analysis was contrasted with Multiple Regression. Our results highlight the importance of the interdependence of multiple factors. Linear regression is very limited when accounting for such interdependence. In fact, the higher the interdependence among independent variables, the less reliable the regression coefficients, because of multicollinearity. In addition, linear regression imposes a linear functional form on the relationship between independent and dependent variables, which may not necessarily reflect reality. Finally, the way in which the regression line is estimated is sensitive to influential observations. While MCA cannot estimate the effect of one variable on another as regression does, it does not rely on assumptions of functional forms and fully incorporates interdependence. See [47]. In addition, outliers do not influence results because they become part of one of the categories. An extensive discussion of the differences between MCA and linear regression is outside the scope of this paper, and we are not claiming that MCA is a better technique than Linear Regression. However, our results do suggest that extreme care should be taken when deriving prevention and policy implications from specific statistical techniques. We suggest that structural interdependence and qualitative techniques are highly informative because they do not rely on assumptions of functional forms and specific characteristics of the data and that triangulation of methods is highly advisable. For instance, our findings regarding the perception of availability of drugs being a determinant factor of early initiation through both methods suggest that this is an RF that should be prioritized. MCA, however, does not provide information about moderating effects involving RF and PF. Multivariate regression techniques offer the possibility of constructing and analyzing interaction terms that capture such effects. Future work may attempt to combine the two approaches. Another potential limitation of using MCA is that the categorization of variables that are inherently continuous, such as age of initiation, requires cut-off points for making groups of participants. It is arguable that different ways of forming groups may yield different outcomes. If the data and theory allows it, sensitivity analyses using alternative categorizations may offer relevant robustness checks. In this work, we used cut off points that were both consistent with the literature and empirically practical. An additional consideration is necessary in relation to the cross-sectional nature of our data. Young adolescents that were classified as "never" along to "over 17" age of onset, may decide to use substances in the near future. Our data cannot capture such dynamic. An extension of this work, using a longitudinal design, may test the present results by tracing the behavior of a cohort of young adolescents until they turn 17. Regarding specific RF and PF, our analyses highlight that the effect of a perceived availability of drugs remarkably persists across different methodologies, suggesting that such perception must be prioritized in health policy. Note that such a perception is influenced by public policy at different levels including the way in which the police controls and takes action with respect to micro traffic and consumption. This result is consistent with the work of Tucker, Pollard, De La Haye, Kennedy and Green [48] who found that the perceived availability of drugs was related with higher rates of cannabis use among adolescents in the Check Republic, which displays the highest rate of substance availability in Europe, with an increasing prevalence of cannabis use per year. Thus, perception of availability must be taken into account in the debate on legalization and/or decriminalization of some substances, totally or partially. As it pertains to the other RFs and PFs, our results show a staggering contrast between Multiple Correspondence Analysis and Multiple Linear Regression. While MCA suggest that priority should be given to environmental-based prevention focused on community and social factors, regression results suggest that the focus should instead be placed on family factors. The MCA results are consistent with the notion that early initiation, which occurs during early adolescence, is highly sensitive to broader contexts . In their decisions for the pursuit of identification vehicles outside the family, adolescents are experiencing a process of decreasing relevance of the family environment [49]. In Colombia, the scant research on RF and PF in connection to the age of onset is consistent to the results found by regression analysis. It is reported that the absence of close family members who use drugs and the existence of parental supervision is associated with greater resistance to initiate [50]. Furthermore, age of onset among Colombian adolescents was also found to be indirectly influenced by family conflict when serially mediated by negative emotions and sensation seeking [31] Preventing SUDs is a major objective of health policy. In this paper, we focused on early initiation of drug use during adolescence, as a relevant behavioral antecedent of various types of SUDs. Delaying the age of onset of substance consumption may be one of the most effective ways to reduce SUDs. However, there are multiple causes and complex psychosocial dynamics behind the decision of a young teenager to start consuming drugs. This study contributes to understanding these causes by assessing early initiation relationship with multiple RF and PF in the adolescent's proximal and distal environment, using a statistical method that explicitly accounts for the interdependencies of all the factors studied. We provide new insights into the nature of the relationships between RF, PF, and early initiation as well as the application of a methodological tool to assess it. --- All relevant data are within the paper and its Supporting Information files. --- Supporting information --- S1 Table. Summary of RF and PF category cutting points. --- S2 Table. Multinomial ordered logistic regression of early initiation on RFs and PFs. ---

One of the major goals of drug use prevention programs is to delay the age of onset of substance use. What is called early initiation, usually occurring in adolescents under the age of 15, is a salient predictor of Substance Use Disorders later in adulthood. The causes of early initiation are complex and multifaceted and this has led to the identification of a rich set of risk and protective factors that influence age of onset. Nonetheless, there is little knowledge about the interdependence of these factors in their impact on early initiation. This paper addresses this question by applying Multiple Correspondence Analysis to data on family, community and social risk and protective factors from over 1200 adolescents. We find that community and to a lesser extent social factors are the most clearly associated to early initiation and we compare our results to those obtained from linear regression analyses of the same data that do not incorporate interdependence and find opposite results. We discuss the differences between linear regressions and MCA to evaluate the interplay of risk and protective factors and the implications of our findings for health policy and the design of prevention interventions aimed at delaying age of onset.

bear the additional burden of elevated anti-Asian sentiments and attacks . Such experiences and perceptions of heightened racial discrimination may act as a chronic social stressor that exacerbates adverse mental health among Asian Americans and contribute to the existing rise in mental health struggles among Asian American adolescents and young adults. AA adolescents and young adults are the fastest growing racial and ethnic population segment in the U.S. . Adolescence is a stage of rapid physical, social, and brain development; thus, AA adolescents and young adults may be especially vulnerable to increased depressive symptoms due to their exposure to multiple stressors associated with the COVID-19 pandemic, such as increased social isolation, family financial strain, and increased social media use. They also feared for their own safety as they became direct targets of anti-Asian hate crimes . Additionally, the health and well-being of adolescents . Among adolescents aged 12-17 years, ∼18.6% of non-Hispanic Asians have reported ever experiencing a major depressive episode, compared to 23.4% of non-Hispanic White/Caucasians, based on nationally representative data from the 2019 to 2020 National Survey on Drug Use and Health . Among Asians from this dataset, about 24.5% Filipino, 20.3% Indian, 18.8% Vietnamese, 18.1% Japanese, 18.0% Korean, and 13.2% Chinese have ever experienced a major depressive episode . Across all Asian American adult age groups, young adults aged 18-25 years, comprised the highest group ever experiencing a major depressive episode, according to the 2019-2020 NSDUH. AA adolescents and young adults are in a unique rapid developmental period, which makes them especially vulnerable to racial discrimination, heightening the anti-Asian climate during the pandemic. These adolescents and young adults are experiencing increased identity exploration and formation that is strongly tied to their racial/ethnic background and how their racial/ethnic identities are perceived by others . For example, one study found that Chinese American young adolescents who faced fewer developmental difficulties were associated with parents who socialized their children about maintaining their cultural heritage . These effects were not observed among older adolescents. However, the study found that both young and older adolescents with more developmental difficulties were associated with parental messages about concealing one's racial/ethnic identity during COVID-19 . Despite the growing recognition of the rise of anti-Asian racism in the era of COVID-19 in the national dialogue, there remains a data gap on the consequences of this increased racial discrimination on AA adolescents and young adults' mental health and well-being in the U.S. Without robust data, it is not possible to understand the breadth and depth of the intertwined effects of racism, violence, and mental health outcomes that can facilitate the design of effective and age-/culturallyappropriate public health policies and interventions to support this population group. This climate of racial discrimination may be attributed to Orientalism and Sinophobia. Coined by Edward Said, orientalism is a framework to understand the colonial relationship between the West and the East. The East and its people, including Asia and the Pacific, are viewed through the Western gaze as subservient, savage, and in need of civilizing by the strong, sophisticated West . Contemporary anti-Asian racism during the COVID-19 pandemic has manifested in ways that build on this historical Orientalist context, specifically fomenting Sinophobia . In particular, those racialized as Asian in the U.S. have been flattened into a monolithic group and all assumed to be Chinese, and subsequently blamed for geopolitical tensions between the U.S. and China. As a result, those racialized as Asian in the U.S. are viewed as vectors of disease that could harm the U.S. body politic . The socio-ecological framework can be used to understand the multi-level structure and impacts of Orientalism. McLeroy et al. ecological model for health promotion posits that nested environmental levels affect individual behavior and health outcomes and vice-versa . As a macro-level ideological geopolitical climate, Orientalism structures the psychosocial and economic pathways that may impact the health of AAs. At the policy level, disinvestment in and gentrification of Chinatowns and other Asian ethnic enclaves throughout the U.S. reveal the structural violence in working-class communities, placing them at increased risk of poorer health outcomes . At the community level, this simultaneous disinvestment and gentrification occur because Chinatowns and other Asian ethnic enclaves represent sites where the working-class AAs are diseased and dirty , and therefore in need of sanitizing to fit an upper-middle class White aesthetic . At the interpersonal level, AAs, especially women, transgender, and gender non-conforming people, have been subject to racial discrimination, public harassment, and physical and psychological violence in places such as sidewalks, subways, and social media . These pathways can all influence AAs' mental health by exposing them to direct harm, chronic stress, feelings of hypervigilance and by undermining their sense of safety and belonging. Moreover, for AA adolescents and young adults, healthy racial and ethnic identity formation processes can be disrupted . In this article, our objective is to conduct a rapid assessment survey describing the perceptions and experiences of anti-Asian racism and depression severity prior to and during the COVID-19 pandemic among AA adolescents and young adults. We hypothesize that our online-recruited U.S. sample of AA adolescents and young adults are experiencing decreased levels of personal safety and increased levels of depression symptoms associated with either personal experiences or perceptions of a surge in anti-Asian sentiments, hate crimes, and violence during the ongoing pandemic. Findings from this survey can help illuminate opportunities for health policymakers to invest in infrastructures that effectively improve the mental health statuses of AA young people impacted by recent anti-Asian hate during the COVID-19 pandemic. . /fpubh. . . Methods --- . . Study design and sample This study used data from the Young Asian American Health Survey , an anonymous, self-administered, online cross-sectional survey for Asian American adolescents and young adults living in the United States. The YAAHS questionnaire was developed by the authors of this report. We adopted questions about personal experiences and perceptions of violence/harassment from the Pew Research Center's American Trends Panel survey, included the validated Patient Health Questionnaire-9 instrument widely used in the general population to assess depression status, and incorporated a few open response questions about people's experiences with and perceptions of anti-Asian violence/harassment. Before dissemination, we piloted our survey with a small group of Asian/Asian American adolescents and young adults to ensure our questionnaire was feasible, appropriate for a broad range of literacy levels, and relevant. We solicited volunteers for our pilot test via emails to our community partners' listservs and our social networks and ended pilot testing after 1 week. Based on feedback from our pilot participants on the readability of our survey, we distributed our survey in English only. We recruited study participants through direct contact via e-mail and postings on social media sites such as Facebook, Instagram, and Twitter. Population Council's IRB reviewed and approved this study for conducting human subjects research. The survey and datasets generated for this study can be found in the study's page on the Harvard Dataverse Repository . We focused specifically on people who are racialized as Asian and Asian American, while excluding individuals who identify as Pacific Islanders. While Asians and Pacific Islanders are often grouped together, this obscures the distinct political, social, and economic histories of two heterogeneous groups. Pacific Islanders including Native Hawaiians, Samoans, Chamorros have actively resisted being lumped with Asian and Asian Americans because of their experiences with U.S. settler colonialism and indigeneity . Since our study specifically seeks to better understand anti-Asian violence in the context of the COVID-19 pandemic during which more visible Orientalism and anti-Chinese geopolitics were observed, we restricted our scope to those identifying as Asian Americans. In doing so, we sought to resist the problematic grouping of Asians with Pacific Islanders and be able to highlight the experiences and impact of racism on Asian Americans to direct appropriate actions. Survey responses were collected through SurveyMonkey from May 2021 to March 2022. Our eligibility criteria for being included in the study sample was self-identifying as Asian/Asian American, living in the US during the pandemic, and being between the age of 13-29. Among the 323 people who initiated a survey response, 306 respondents met our eligibility criteria. However, 130 of the eligible respondents were missing information on all key exposure variables; most of these missing cases were from unfinished questionnaires . Respondents who had incomplete data were not significantly different on race, ethnicity, or depression severity compared to those who had complete data. Therefore, we excluded respondents with incomplete data in our analysis, making our final analytical sample 176 participants. --- . . Key measures The survey asked close-and open-ended questions regarding participants' personal experiences and perceptions of anti-Asian violence before the pandemic and during the pandemic when there was a rise in anti-Asian violence, depressive symptoms, sociodemographic characteristics, and coping mechanisms under the current climate. There were also open-ended questions to elicit qualitative explanations for some of these items. --- . . . Anti-Asian violence . . . . Experiences of anti-Asian violence Participants were asked whether they experienced the following types of harassment and/or violence in-person or online before the pandemic : offensive name-calling, purposeful embarrassment, physical threats, vandalism or destruction of personal property, and physical attacks. Participants then indicated if and how their personal experiences with each type of harassment had increased since the pandemic begun: yes, in frequency; yes, in severity; yes, in both frequency and severity; no; or not applicable. For analyses, we grouped all "yes" responses into one category and then created aggregate measures of whether they experienced any type of in-person and/or online harassment before the pandemic and whether their experiences of harassment had increased since the pandemic . --- . . . . Perceptions of safety and of anti-Asian violence Participants were asked if they felt safe in their current neighborhood and to rate how safe they felt in their city/town now compared to how they felt before the pandemic . Participants then reported if they had avoided public spaces due to fear of being a target of anti-Asian violence since the pandemic started . Participants also rated their perceptions of changes in level of anti-Asian violence since the pandemic started; responses were dichotomized as a little worse/much worse vs. the same/little better/much better than before the start of the pandemic. Additionally, we asked participants to provide responses to open-ended questions on: how they felt when they saw or heard about events related to hate crimes and racism toward Asian individuals and communities since the start of the pandemic; how the level of anti-Asian violence has changed since the start of the pandemic; and specific changes in their movements or behaviors in public spaces since the start of the pandemic due to fear of being a target of anti-Asian violence. --- . . . Mental health outcomes Recent depression severity was measured using the 9-item Patient Health Questionnaire , a commonly distributed questionnaire and diagnostic instrument assessing the degree of depression severity . Items asked about the frequency of experiencing problems related to the 9 DSM-IV criteria in the past 2 weeks, rated on a 4-point scale . Items were summed to generate a total score of depressive symptoms , with higher scores representing greater depression severity. Statistical reliability of the measure was high . Because total PHQ-9 scores were skewed and not normally distributed, for analyses, responses were categorized by level of depression severity according to the depression diagnostic status and then dichotomized as low vs. high depression severity. Increase in depression severity: Participants were also asked to rate the degree to which their feelings of depression have been bothering them now in comparison to before the pandemic on a 5-point Likert scale . Responses were dichotomized as much less than before/a little less than before/the same as before vs. a little more than before/much more than before. --- . . Analysis We obtained descriptive statistics of sociodemographic characteristics , experiences and perceptions of anti-Asian violence, and depression severity for the study sample. Around 25% of our sample did not report their exact age in the survey. Therefore, we instead used participants' responses to their current school grade to infer their age; people who were in middle or high school were assumed to be adolescents below 18 years old, and those who were in college, in post-graduate school, or not currently in school were assumed to be young adults between the ages 18-29. We ran Fisher's exact tests to examine the bivariate relationships between sociodemographic characteristics, depression severity, and experiences and perceptions of anti-Asian violence. We used Fisher's exact tests to assess associations between our categorical variables because the test is valid for all sample sizes, whereas Chi-square tests of independence may be unreliable when the sample is small, particularly for scenarios of low expected cell frequencies . For the bivariate analysis comparing depression severity and experiences/perceptions of anti-Asian violence by ethnicity, we included a subcategory of "mixed ethnicity" alongside subcategories for East Asian, Southeast Asian, South Asian ethnicity, since participants could select more than one ethnicity they identified as. Statistical significance was set to the p < 0.05 level. To complement the quantitative results, we conducted thematic analysis on the open-ended responses regarding their experiences with and feelings about anti-Asian violence and harassment during the pandemic. For each open-ended question, we reviewed all responses, developed codes to describe the content, identified patterns among the codes to create themes, and reviewed and refined the themes generated. We reported the most common theme for each open-ended question and included excerpts of written text from respondents that encapsulate the main theme in the results section. Coding was conducted in Microsoft Excel. a minority being gender queer/nonbinary. Most participants identified their race as Asian only, while 20% indicated an additional race . A fifth of respondents were born outside of the U.S. Most of our sample were young adults between the ages 18-29 , and two-thirds of participants were currently in school: 15% were in middle or high school, 31% in college, and 11% in post graduate school. Figure 1 displays the frequencies of experiences with anti-Asian harassment and depression severity before and since the COVID-19 pandemic started among our sample. Sixty percent of participants reported experiencing in-person, anti-Asian harassment before the pandemic and 39% reported experiencing online harassment. About a quarter of participants said that the frequency and/or severity of their personal experiences of in-person or online anti-Asian harassment has increased since the pandemic started. --- . Results Only 14% of participants indicated that they currently felt unsafe in their own neighborhood, but more than half reported avoiding public spaces since the pandemic started due to fear of being a target of anti-Asian violence. When asked to select from a list of what precautions they have taken to avoid anti-Asian violence, 75% of the sample reported that they avoided going to places alone, 64% avoided going places at night, 45% avoided specific neighborhoods or locations, and 23% begun carrying pepper-spray or mace. In an open-ended response question about their changes in movement or behaviors in public spaces since the rise of anti-Asian violence during the pandemic, many participants stated that they do not go out as often as before the pandemic. If they do, many said that they try to be more cautious and vigilant of their surroundings and often feel uncomfortable and anxious in large, public spaces. For example, one participant said: "I no longer ride the subway alone, and try to avoid using the subways at all if I can ... I purchased an annual Citibike membership in part to have an alternative method of transportation other than the subway." Most participants reported feeling less safe now than before the pandemic , and the majority indicated feeling like the level of anti-Asian violence had gotten worse since the pandemic started. When asked about how the level of anti-Asian violence has changed, many participants noted that although racism against Asians existed before the pandemic, the xenophobic rhetoric surrounding COVID-19 has amplified anti-Asian sentiment and increased the media coverage of anti-Asian incidents: "Anti-Asian violence has always been present, yet our community didn't talk enough about it. Now, people are just blatantly being more violent and racist. . . it is undeniably true that after Trump's unacceptable name calling against the Asian community about COVID-19, that a rise in those crimes happened." "Hate crimes toward Asians have increased 8 fold. every time a major event like this occurs, america finds a scapegoat to thrust their violence onto. . . east and southeast Asians are taking the brunt of the violence because of covid." . /fpubh. . --- TABLE Distribution of sociodemographic characteristics by perceptions and experiences of anti-Asian violence and depression severity during the pandemic among YAAHS respondents (N = ). In an open-response question asking participants how they felt when they saw or heard about hate crimes and racism toward Asian individuals since the pandemic started, the most common responses were feeling sad, angry, worried, frustrated, fearful, disappointed, anxious, scared, and hopeless. Additionally, several participants described feeling especially hurt and disturbed when seeing older Asian adults being targeted for hate crimes, leading them to be particularly concerned for the safety of their older family members and relatives. For example, a 17-year old Vietnamese man wrote that he felt "scared for my family, especially my grandparents and parents". --- Felt less safe since the pandemic Forty percent of our sample experienced moderate, moderately severe, or severe depressive symptoms in the past 2 weeks , and two-thirds indicated that their depressive symptoms have increased since the pandemic started. Most participants had engaged in some type of coping mechanism for dealing with the negative sentiment toward Asians since the pandemic began, including talking to their friends about it , talking to their family , reading about how to cope with it online , going to therapy , and participating in a support group online . Table 2 shows the sample distribution of those who experienced and perceived increased levels of anti-Asian violence since the pandemic and reported high depression severity by sociodemographic characteristic. A significantly larger proportion of participants who identified as mixed-race Asian reported an increase in experiences of anti-Asian harassment since the pandemic begun compared to those who identified as single-race Asian . Participants who were middle/high school or college students were significantly more likely to report high depression severity than participants who were in post-graduate school or not currently in school . A significantly greater proportion of participants who were cisgender women or transgender/genderqueer had high depression severity compared to participants who were cisgender men . Most notably, transgender/genderqueer and cisgender women participants were significantly more likely to feel less safe now than before the pandemic compared to cisgender men . . Figure 2 displays the distribution of participants' perceptions of safety and anti-Asian violence by personal experiences of harassment following the pandemic. Participants who indicated experiencing increased levels of harassment since the pandemic were significantly more likely to indicate feeling unsafe in their current neighborhood and feeling less safe now than before the pandemic compared to those who did not experience increased harassment or never experienced harassment. These participants were also more likely to report avoiding public spaces due to fear of being a target of anti-Asian violence and using coping resources since the pandemic started than those who reported no increase in or never experienced harassment. These findings suggests that increases in personal, direct experiences of anti-Asian harassment during the pandemic contributed to decreased feelings of safety after the pandemic started. Table 3 presents the distribution of depression severity by experiences and perceptions of safety and of anti-Asian violence since the pandemic. Recent high depression severity was not significantly associated with personal experiences of anti-Asian harassment before the pandemic or perceptions of safety since the pandemic began. --- FIGURE --- Distribution of perceptions of safety and of anti-Asian violence by personal experiences of harassment since the pandemic among YAAHS respondents (N = ). P-values are from results of Fisher's exact tests examining di erences in perceptions of safety and of anti-Asian violence by personal experiences of harassment. Significance codes: *p < . . However, participants were more likely to report that their depression symptoms had increased since the pandemic if they indicated feeling less safe now than before the pandemic , avoiding public spaces due to fear of being a target of anti-Asian violence , and feeling like the level of anti-Asian violence has gotten worse . --- . Discussion The Orientalist climate exacerbated by the COVID-19 pandemic has led to increased public attention toward anti-Asian racism. Prior to the pandemic, Asian American adolescents and young adults experienced varied levels and frequencies of racist harassment and depressive symptoms . Given the U.S. Surgeon General's declaration of the mental health crisis among adolescents and young adults and increased attention on anti-Asian violence, it is imperative that research and public policy must center on the mental health of Asian adolescents and young people . Our study contributes to the emerging evidence base of anti-Asian violence experienced and felt by AA adolescents and young adults during the pandemic and how that is associated with depressive symptoms. These findings provide data for policymakers to invest in age-and culturally-appropriate care for this population. Additionally, study findings have implications on how best to measure depressive symptoms among AA adolescents and young adults. Below, we discuss our key findings. Findings illustrate that most AA adolescents and young adults reported experiencing some form of in-person or online harassment prior to the pandemic. A quarter of the sample indicated that they experienced higher frequency and/or worse severity in harassment since the start of the pandemic. Among these young adults, they were more likely to report feeling less safe and avoiding public spaces due to fear of being a target of anti-Asian violence and having increased depressive symptoms. Additionally, transgender/genderqueer individuals and cisgender women were more likely to report high depression severity than cisgender men in our study. We showed that participants who believed their depressive symptoms got worse during the pandemic compared to before were associated with several predictors: they felt less safe now than prior to the pandemic, avoided public spaces for fear of being a target of anti-Asian violence, and felt like anti-Asian violence had gotten worse during the pandemic. These results contrasted with participants' recent depression severity scores, which measured a respondent's depressive symptoms within the past 2 weeks; those scores were not associated with anti-Asian harassment or perceptions of safety. One potential explanation for this nuanced finding could be that relative changes in perceptions of safety and perceptions of anti-Asian violence before and during the pandemic may not directly determine current mental health status among Asian/Asian American adolescents and young adults but may instead determine relative changes in mental health. Another possible reason could be attributed to the way in which our construct of mental health was operationalized and measured in this study. The PHQ-9 scale may not be sensitive enough to holistically capture the psychological impact of perceived discrimination and threats to safety during the pandemic. More specifically, PHQ-9 assesses clinical depression , but there are other aspects of adolescents' and young adults' mental wellbeing that could be affected by racial discrimination that we did not measure in this study . Future studies should consider a broader range of mental health outcomes to comprehensively explore the effects of anti-Asian racism during the pandemic on the wellbeing of adolescents and young adults who are racialized as Asians in the US. Despite potential limitations in the mental health measure used in this study, our finding that increased perceptions of anti-Asian violence and threats to safety are related to perceived increases in depression severity during the pandemic support previous studies examining the negative and insidious impact of racial discrimination on mental health and adds to the burgeoning literature base on how the rise of anti-Asian racism during the COVID-19 pandemic has worsened the mental health of Asian Americans specifically . In addition to experiencing many of their formative schooling years online, due to pandemic safety precautions, Asian American adolescents and young adults' intentional avoidance of public spaces for fear of racial violence can come at the cost of sustaining social connection to support systems and having a sense of belonging in their neighborhoods, all of which may have long-term mental health consequences across the life course . Specifically, these experiences of isolation and anti-Asian racism may contribute to Asian American adolescents' developmental trajectory, which may be in more flux than young adults, such that it increases fear and mistrust of others, promoting intergroup hostility, concealing one's culture, and hinder positive identity development . Furthermore, our results on depression severity by gender, highlight and endorse the gendered disparities in mental health and experiences of violence . Cisgender girls and women, transgender, and genderqueer participants reported higher depression severity than cisgender boys and men. Scholarship in Asian American Studies and mental health show that the relationship between gendered racism and mental health is precipitated by labor, war, and migration histories of exotifying Asian women and femmes, subjecting them to misogynistic violence . Thus, future directions need to focus on the most marginalized groups in Asian American communities who are more likely to experience violence and depression. --- . . Limitations Our study conclusions should be considered in light of some limitations. The cross-sectional study design relies on retrospective self-report measures and thus may be subject to biased reporting, constricting our ability to draw causal conclusions or infer directionality. Our data are also unable to distinguish whether participants reported high recent depressive symptoms because of isolation during the COVID-19 pandemic or due to heightened anti-Asian violence. We were, however, able to establish a significant association between increased depression severity during the pandemic and feeling less safe now than before the pandemic because of increased anti-Asian violence. We used the adult version of PHQ-9 for all respondents regardless of age, and respondents ages 13-17 in our sample may have answered the questions on PHQ-9 differently if given the modified version of the instrument for adolescents. Additionally, our small sample size may have lacked adequate power to detect group differences. For instance, the extent to which our results highlighted gendered disparities in depression may be a reflection that over two-thirds of the sample identified as cisgender women and may be more open to recognizing/sharing depression symptoms on an online survey. The overrepresentation of young adults ages 18-29 in our survey may have biased our sample, so we caution against interpreting our study findings to adolescents younger than 18 years old. We also had a fairly large proportion of missing cases in our data due to unfinished questionnaires and were not able to thoroughly mitigate concerns for non-response bias, so findings should be interpreted considering potential selection bias. Furthermore, our convenience sampling design and utilization of a digital survey tool may have led to an over-representation of people who feel strongly about the survey topic and under-representation of people who are not digitally connected or who have restricted internet access, limiting our ability to generalize our study results to the U.S. AA adolescent and young adult population. Despite these limitations, we were able to conduct a rapid assessment of the impact of the rise of anti-Asian violence on the mental health and well-being of a sample of Asian American adolescents and young adults. Our findings support calls to conduct additional research examining the longer-term effects of anti-Asian violence on the health of AA adolescents and young adults and to implement targeted interventions to support their mental well-being. --- . Conclusion YAAHS was launched following the racist and deadly Atlanta shootings of eight women, six of whom were Asian, by a White man . As a team of Asian American researchers, mostly women, femmes, and queer, it is not lost on us that anti-Asian racism and violence predated the COVID-19 pandemic. However, in the midst of a worsening Sinophobic climate, we sought to highlight the experiences of adolescents and young adults who are often left out of the picture. Asian American adolescents and young adults are experiencing multiple health and social crises stemming from anti-Asian racism, COVID-19, and fraught U.S. social safety nets. This requires an investment in violence prevention measures for both online and in-person settings from local and national public health and education officials. We insist officials, especially those in middle and high schools and colleges to encourage and promote a culture of reporting anti-Asian hate crimes and other hate incidents by promoting and investing in anti-hate campaigns and mental health services in public forums, and offering trainings focused on anti-racism and bystander intervention. Moreover, study results support the need for increased age-and culturally-appropriate mental healthcare and social support interventions for Asian American adolescents and young adults whose developmental trajectories may be affected. While our study did not specifically point to structural interventions, we urge policymakers from across sectors to invest in anti-carceral infrastructures of healing, safety, and support for those who are at risk for and impacted by anti-Asian hate and violence. Lastly, we write directly to Asian American adolescents and young adults: we see you and the pain that you are going through. Rather than lean into social isolation, fear, and mistrust, we extend a warm invitation for you to engage in both self-care and collective care. Regarding collective care, we urge you to find community and comfort with one another and with the many Asian American social justice groups around the country fighting for and with you. --- Data availability statement The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s. --- . /fpubh. . --- TABLE Distribution of perceptions of safety and anti-Asian violence since the pandemic by depression severity among YAAHS respondents (N = ). --- Recent depression severity --- Ethics statement The studies involving human participants were reviewed and approved by Population Council IRB. Written informed consent from the participants' legal guardian/next of kin was not required to participate in this study in accordance with the national legislation and the institutional requirements. --- --- --- Publisher's 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.

Objectives: We describe the perceptions and experiences of anti-Asian racism and violence and depression severity prior to and during the COVID-pandemic among a sample of Asian American (AA) adolescents and young adults.We used data from the Young Asian American Health Survey (YAAHS), an online-recruited sample of AA adolescents (ages -) and young adults (ages -years) conducted during May to March . We presented descriptive statistics examining the univariate distribution and bivariate relationships of depression severity, sociodemographic characteristics, and experiences and perceptions of anti-Asian violence.) comprised AA adolescents and young adults from Asian ethnicities. A quarter said that the frequency and/or severity of their personal experiences of anti-Asian harassment had increased since the pandemic started. % indicated feeling less safe now than before the pandemic. Two-thirds reported that their depressive symptoms have increased since the pandemic started. Participants who reported feeling less safe now than before the pandemic were more likely to report increased personal experiences with anti-Asian harassment and increased depression severity since the pandemic started than those who reported feeling as safe or safer before the pandemic (p < . for both). Discussion: Findings illustrate AA adolescent and young adults are experiencing multiple health and social crises stemming from increased anti-Asian racism during the COVID-pandemic. We urge policymakers to strengthen data systems that connect racial discrimination and mental health and to institute prevention measures and anti-racist mental health services that are age-and culturally-appropriate for AA adolescent and young adults. KEYWORDS mental health, Asian Americans, adolescents, young adults, anti-Asian racism, harassment, depressionMental health conditions are increasing worldwide and are shaped by a variety of social factors, and racial discrimination in particular has been found to significantly impact risk for depressive symptoms among racially minoritized groups (1, 2). While the threat of the COVID-19 virus and pandemic effects are real for everyone living in the U.S., Asian Americans

Introduction Sub-Saharan Africa is currently experiencing the fastest growing and youngest population globally. The annual population growth rate in SSA stands at 2.4%, the fastest in the world, a third of which is below 24 years of age [1][2][3]. The rapid increase in population translates into a combination of increased demand for nutritious food and generation of food waste. According to Sheahan and Barret [4], the annual per capita food loss/waste ranges between 120 and 170 kg. This ends up in landfills, posing an environmental and health burden to the surrounding population [5,6]. Consequently, the increasing population will result in increased food waste availability, further aggravating the food waste associated challenges. Food waste refers to the decrease in the quantity or quality of food resulting from decisions and actions by retailers, food service providers and consumers [7]. The Waste Framework Directive 2008/98/EC defines waste as "any substance or object which the holder discards or intends or is required to discard" [8]. Hence as food deteriorates along its value chain and it is no longer fit for the intended purpose, it is discarded, compromising food security and promoting malnutrition. In industrialized countries, the majority of food is wasted at the retail and consumer stages, while in low-income countries, food is often lost in the production or processing stages of the supply chain before it even reaches the consumer [9]. Food waste is implicated to lead to a myriad of challenges and lost opportunities to value chain actors and the general population. These include: loss of investment and profit associated with the wasted food, and burdening the environment through emitted leachate; greenhouse gas emission, process, transport and later on dispose food that is ultimately not utilized; and acidified greenhouse gases among others [9,10]. Food lost through wastage definitely impacts food security negatively. Despite the above negative connotations, food waste has alternative uses such as animal feed, compost/fertilizer, and energy generation in the form of bio-gas, among others [11,12]. Makanjuola et al. [13] propose several products from food waste such as dietary fibre, biofuels, colorants, enzymes, livestock feed, food supplements and essential oils among other prospects. Discarded food is only spoiled and unfit for human consumption but not devoid of value. It still carries value and need not be disposed of without extracting this value from it, i.e., value addition. Given that food waste is to be used as the raw material for value addition purposes, it is important to characterize the supply of the waste in preparation for reliable and sustainable production of the intended value-added products. In East Africa, Uganda inclusive, it has been documented that biological waste, much of which is food waste from restaurants and markets makes up 65-79% of the total solid waste in major cities [14]. Therefore, of the 481 kt of solid waste collected in Kampala [15], food waste could therefore be estimated to range between 312 and 380 kt by 2019. The latter estimations did not quantify the types and amounts of food waste yet this is crucial in food waste value addition, especially for conversion into livestock feed. For the latter, it is important to know which food wastes can contribute to the different key nutrients such as protein in the feed, and how they will be sourced. This study intended and therefore: quantified the types and amounts of the food waste proportion, and assessed the attitudes and practices of the food waste generators towards its disposal and potential use. --- Methodology --- Study area and data collection The research was conducted in Kampala city, the most urbanized area in Uganda. This area is characterized by a high density of households, institutions and markets. Kampala city consists of five divisions and nine constituencies, the latter being sub-divided into parishes, and local councils. There are five companies contracted by Kampala Capital City Authority to collect and dispose solid waste at Kiteezi landfill. The sample size was estimated using Cochran's sample size formula [16], i.e., sample size, N = /e 2 where: e is the desired level of precision , Z is the Z value associated with the confidence interval associated with e, p is the proportion of the population which has the attribute in question, q is 1 -p, and 1 is the population size. In this study, the total population and the proportion disposing food waste in Cochran's formula were estimated from the Uganda population census [17] findings as follows: a. About 97% of the population in Kampala city was comprised of households and women were mostly in charge of preparing and discarding food items. Thus, the population size for use in Cochran's formula was 0.97. b. Of this total population, 57% of the population of the households were in a marriage , contributing to the 0.57 of the proportion of the key population disposing food; and 13% of the households were widowed and separated persons. Hence, the proportion of the population directly contributing to food waste generation and disposal, i.e., p in Cochran's formula was estimated was estimated as the sum of 0.57 and 0.13, i.e., 0.7 . c. Given that the persons responsible for trading food in markets and preparing food in the institutions are much smaller in number, and they also belong to the households as well, using the household population to estimate the respondent sample size was adequate and justified. Hence, with N = 0.97, i.e., ~ 1, Z = 1.96, p = 0.7, q = 0.3, and e = 0.05, the sample size was estimated at 323 respondents. For a better distribution, 330 respondents were interviewed. Of the 330 respondents, 150 were allocated to markets and institutions for equal divisibility among the components, while the remainder, 180 respondents, were allocated to households. For markets, respondents dealing in raw staple food items/fresh produce were interviewed. In each division, the biggest market dealing in fresh produce was visited according to information obtained from division headquarters. These included Nakawa market , Kalerwe market , Busega market , Kibuye Market , and St. Balikuddembe and Nakasero markets . In each of these selected markets, the market leadership was asked to lead us to three traders dealing in each of the following five staple food items, i.e., Matooke, Cassava, Sweet potatoes, Irish potatoes and green leafy vegetables. Hence, from five produce markets, a total of 75 respondents were selected. For institutions in each division, a list of major hotels, restaurants and schools was obtained from the division headquarters and using the random selection method, five of each of the institutions were selected and surveyed from each division. Thus 75 institutions were surveyed. The total number of hotels and restaurants in Kampala was obtained from the Uganda Bureau of Statistics. For households, 180 respondents were visited in the five divisions. From each of the two constituencies in a division such as Rubaga North and Rubaga South in Rubaga division, a parish was randomly selected from the each of the constituency parish list. For Kampala central that is one constituency, two parishes were randomly selected. From the 10 parishes selected, 18 residential households were interviewed per parish. When an enumerator reached the selected parish, he/she interviewed every 5 th household from the preceding one. The mothers in the households were the target respondents. A team of well-trained enumerators pre-tested the data collection tool and implemented the survey. --- Data management and analysis Data sets were cleaned to remove unnecessary digital information, re-organized and imported to SPSS software for analysis. Data sets were presented in terms of frequencies and percentages of respondents' response to the parameters under investigation. Logistic regression was performed to gain insights into relationships that can exist between the demographic characteristics of the respondents and their practices and attitudes towards food waste. Findings were presented in the form of tables and figures to aid interpretation and further discussion. --- Results and discussion --- Social-demographic characteristics of the respondents In Table 1, we present the descriptive statistics of the information collected from the households, institutions and markets. Majority of the respondents were youth aged between 18 and 35 years, followed by adults aged between 36-60 years. This is in line with other study findings on food waste, which show similar age bracket patterns. A study in Albania [18], using 185 respondents found youths to constitute 50.2% of the respondents, while 34.6% were adults in the 35-54 age-group. Charbel et al. [19], in Lebanon had 215 respondents with youths constituting 63.7%, and 28.9% adults between 35-54 years. This implies that regarding food waste demand and supply, youth and adults are the most important age-groups to be considered for policy planning purposes. Majority of the respondents had attended either primary or secondary education and therefore attained the minimum literacy level to enable them read and write. Considering food waste as a resource that can lift many stakeholders out of poverty, literacy is therefore a resource to support life-long learning in the fast changing world that now considers waste as a resource [20]. This makes extension services regarding improvement of waste management easily comprehensible by the stakeholders. Majority of the respondents were married, and therefore potentially having more than one person living in a household. This implies increased food waste generation compared to households with single persons that were the second most abundant in the survey. Women in households, chefs in the institutions, and business owners in markets were the gatekeepers of waste generation and hence management. They are the key to implementing interventions aimed at improved food waste management. However, in the SSA setting, husbands are the household heads and normally control any resource that has financial gains [21]. Likewise, in schools, restaurants and hotels, although the former was identified gatekeepers, business owners are most likely to determine the fate of the food waste once the waste is identified with financial gains. Therefore, alongside the gatekeepers of waste generation and disposal, the final decision makers need to be involved in the waste management improvement interventions if they are to succeed. For households, majority reported having 2-3 meals per day which implies increased food waste generation. Of the five household members, at least two of them earned an income which possibly helps them to currently pay for the disposal of their waste. --- Sources and frequency of food waste generation In Table 2, we present the descriptive statistics for the sources and frequency of food waste generation. Findings show that markets are the major source of food supply to households and institutions, while markets obtain their food items mainly from farmers and whole-sale stores. Farms, farmers' markets and supermarkets are the least suppliers of food items. Over 90% of the respondents in markets and households, and 72% in institutions experienced food waste in a week. Institutions experienced/generated food waste most frequently on a daily basis while for households and markets, the frequency of food waste generation averagely ranged between once and three times a week. Across all the categories, 2.9-14.4% of all the respondent categories at least experienced food waste on a daily basis. This information is useful to food waste collection/ aggregation for value addition. For example, food waste can be collected on a daily basis from schools, hotels and restaurants while for households and markets, it can be two or three times a week. Over 68% of the households were not willing to grant permission for their waste to be weighed, however, this information was obtained from the 32% who were willing. To the contrary, majority of the respondents from institutions and markets were willing to have their waste weighed, and this information was useful in estimating average quantities of types of food wasted by each category. The willingness by institutions and markets to have their food waste weighed compared to households is possible because waste is generated daily. This willingness combined with daily generation implies that institutions and markets can be consistent sources of daily food waste to its value addition centers. Consistence in raw material supply is critical in value addition [22]. --- Food waste supply from households, institutions and produce markets Table 3 shows the types and average amounts of the types of food waste identified. Banana peels and leftovers contribute 33.3% of the food waste supply followed by cassava peels and left over stems that contribute 27.9%. These are followed by Irish potato peels, left-over foods from cereals and pulses and lastly, leftover foods from animal source foods such as fish and meat. These findings have important implications regarding; the availability, accessibility and affordability of foods in Uganda; the consumption patterns of these foods, and the formulation patterns for animal feeds. In Uganda, matooke and cereals such as maize and rice are the staple foods followed by tubers , pulses and lastly animal source foods [23,24]. The annual per capita consumption of high quality animal protein and micro-nutrient rich foods is low, i.e., estimated at 13.4 and 33.9 kg cap -1 yr -1 for meat and milk respectively compared to the world's consumption estimated at 45.3 and 89.5 kg cap -1 by 2030 . Consequently, Ugandans largely depend on plant based foods and less on animal based foods [25] which is consistent with their food waste behaviour. Plant foods hence make the biggest percentage of food waste, consistent with observations in this study. In animal feed, the highest requirement is energy followed by protein and other nutrients [26]. The energy sources in animal feed majorly consist of carbohydrates and fats. Matooke, cassava and cereals in this study are carbohydrate sources and therefore potential sources of energy in animal feed. Pulses normally complement animal proteins as sources of protein and other nutrients in animal feed formulations, with the latter existing in the least amounts. Beans and groundnuts in this study can therefore complement fish, meat and poultry for use in animal feed. On average, 680 t of food waste are generated daily from households. Households and markets supply a variety of food waste material but collecting the waste often requires considerable investment in labor for collectors, i.e., those who transfer the waste to the skip and the garbage collection company employees; automobiles and their maintenance; fuel and disposal costs at landfills [27,28]. On the contrary, markets and institutions provide few types of food waste but in large amounts that aid bulk collection. Currently, food waste collection is mainly done by private companies that solicit money from waste generators to dispose of their waste. Therefore, waste generators could find it beneficial and attractive if there is an offer to dispose of their waste at no cost. Similarly, interested parties in food waste value addition can aggregate waste at no fee. --- Reasons for condemning food to waste Figure 1 depicts the reasons for condemning food to waste. Findings show that moulding, poor food storage, food being leftover, and food expiry were the major reasons by the households and institutions for condemning food to waste. For produce markets, food being leftover does not apply but presence of food in excess of what could be sold, bad aroma, bad taste, and poor storage were cited as major causes of food waste. Normally, moulding and loss of sensory appeal are signs of food losing its edible quality and subsequent spoilage, becoming unfit for consumption [29,30]. Poor storage can contribute to molding/spoilage of food. This implies that loss of aesthetic appeal, food expiry and food excess are the major causes of food wastage, and preventing these factors or reducing their occurrence can reduce food wastage. Several measures such as raising awareness, improving communication along the food supply chain to match demand, and improving post-harvest handling, Table 3 Types and daily estimates of food waste generated by households, institutions and produce markets a The total number of households in Kampala b The coverage collection of solid waste in Kampala c The number of restaurants and hotels in Kampala d The number of produce vendors in Kampala major markets. The tons of food waste per day were obtained by multiplying the average waste collected by the number of HH and the coverage for HH; the number of hotels and restaurants for institutions; and the number of vendors for produce markets processing, storage, transportation and retailing have been suggested by FAO [31]. Though no strategies exist in many SSA countries to reduce food waste, some regions such as the European Union has have come up with the "farm to fork" strategy to prevent food loss [32]. The United States Department of Agriculture and the Environmental Protection Agency established the U.S. 2030 food loss and waste reduction goal, seeking to cut food loss and waste in half by the year 2030 [33]. The two programs aim at food waste reduction implying that food waste cannot be completely prevented. Therefore strategies to add value to waste highly contribute to the sustainability of food waste management and circularity of the food economy. --- Food waste component Households Institutions Produce markets Food --- Disposal and utilization of food waste material Figure 2 depicts the disposal and utilization of food waste material. Majority of the respondents in institution and markets, and almost a half of the households indicated that they re-used the food waste. Food waste from markets and institutions is mainly used for animal feed while households use them as snacks during tea breaks. The major use for food waste tends to be animal feed and the wastes are collected daily, majorly at no cost from the persons/institutions from which the food waste is being collected. Food waste is normally used as animal feed [34] implying that it is still laden with nutrients that support animal growth. Given that food waste can potentially transmit diseases such as foot-and-mouth disease and African swine fever to animals [35], and pathogenic microorganisms that pose a health risks to consumers [36], it is important that it is processed for safety and suitability for use as animal feed [37]. Food waste was collected on a daily basis, majorly by a person or company, generally collected together with other kinds of waste and disposed of in either rubbish pits/waste disposal sites or contained in bags/sacks . Majority of the institutions did not pay for disposing of the food waste while majority of the households and produce markets did pay. The lack of food waste segregation/sorting limits its re-utilization because it could be contaminated with materials that do not permit re-use [38]. Therefore, it is important to develop a system that permits segregated/sorted collection of solid waste to enable food waste be allocated for alternative uses. Additionally, protocols to decontaminate food waste and process it into feed and other value added products can encourage sustainable and safe re-use. --- Attitudes and perceptions towards food waste collection, disposal and use Majority of the respondents recognized food waste as a serious problem to worry about especially by the households and the institutions, and impossible to eliminate . However, they were satisfied with the collection systems. This implies that the population is currently seeking for increased efficiency with the current collection systems. Adapting the latter to segregated/ sorted food waste can already support its value addition endeavors and eliminates the need to establish another system. Although the current collection system offers convenience, collection is only at 45% coverage in Kampala [39], implying that majority of the population suffer from inadequate waste disposal of the uncollected waste. Such collection systems can be modified to involve sorting and delivery of food waste to value addition centers instead of landfills. Increased utilization of food waste can result in increased collection coverage because of its demand for value addition purposes. Most of this waste, especially from unlicensed collectors and poor informal households that cannot afford disposal fees dump their garbage in un-gazetted places such as roadsides, illegally constituted dumpsites and the drainage channels which affects the sanitary, hygienic, and environmental health of the surrounding population [14,27]. Majority of the respondents were aware of the benefits of food waste and willing to donate it for alternative uses. The collected food waste was majorly used for animal feed and majority of the respondents were willing to consume livestock raised on food waste. This is an indication of the positive attitude towards innovative value added products from food waste. Positive attitudes towards utilization of innovations is important if such innovations are to be impactful to the intended beneficiaries [38]. --- Effect of demographics on respondents' behaviour towards food waste collection, disposal and use Logistic regressions were performed to ascertain the effect of demographic characteristics on selected practices towards food waste . The demographic characteristics included age, gender, marital status, education level, years of complete schooling, number of rooms in a household, persons earning an income in the household, and occupation. Results indicate that being divorced among the household respondents and having attained lower levels of education among the respondents in the institutions has a positive effect on the re-use of food waste. Low literacy levels and divorce in Africa increases vulnerability to poor livelihood [20]. It is possibly because of the increased vulnerability that re-use of food waste becomes an important consideration. Having more rooms in a household, and the number of schooling years and low levels of education among respondents in the institution were positively related to disposing of food waste at a fee. Respondents with no education had higher odds of paying for food waste compared to the educated ones. This is possibly resulting from these respondents producing higher volumes of food waste and their ability/mandatory requirement to pay for food waste collection services. Education level positively affected the attitude towards food waste as a problem that should be solved. The odds of respondent who are un-educated seeing food waste as a problem were higher than those for respondents with primary level education, which were in turn higher than the ones with secondary level of education. This could be because, either the persons with lower levels of education have limited ability to pay for waste collection services, or they live in areas with limited garbage collection services due to limited support infrastructure such as roads and ability to pay for waste collection [38]. It also implies that awareness should be created among the more educated population about problems associated with food waste even when they don't find it a serious problem. Being married for household respondents and existence for 5-10 years positively influenced respondents willingness to freely give away food waste. This is possibly because disposing of waste would be an additional chore to the married women that they would like off their activity schedule while institutions could be in a phase of growth where they have accumulated the food waste but have not built the capacity to dispose of it, unlike younger institutions that accumulate low amounts of waste or older institutions that have already built the capacity to dispose of it. Marital status , educational level , number of years of schooling, and occupation positively affected the attitude that food waste has benefits. However, higher odds of a thinking that food waste is valuable were associated with the noneducated , being single and un-employed . This could be associated with higher vulnerability that then enables them to seek for new perspectives/ opportunities out of the vulnerability. Such members of the community therefore can be important drivers of food waste value addition. --- Conclusions and recommendations Food waste is recognized as a problem and as a resource with benefits across the three major categories of respondents. Households, institutions , and business owners in produce markets were the gatekeepers of food waste, and therefore the drivers for food waste interventions. However, involvement of key decision makers in households, institutions and markets shall be critical for the success of such interventions. Persons with lower levels of education were positively associated with recognizing food waste as a resource, and paying for its disposal, and hence their sensitization and involvement in food waste value addition chains is key. The respondents recognized the use of food waste for alternative uses such as livestock/cricket feed, manure and break tea escorts among others. Women, especially married; single individuals, and divorced persons were willing to consume livestock such as edible insects raised on feed from food waste. Use of products from food waste can create market and stimulate development and actualization of more interventions towards food waste valorization. Although addressing spoilage, poor storage and excess produce in markets can potentially reduce the amounts of food waste generated, the increasing population may not make this intervention a reality, but recycling/adding value to food waste can. --- --- --- Additional file 1. --- Additional file 2. Additional file 3. --- --- Declarations Competing interests 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. ---

Solid waste management is a major challenge in sub-Saharan Africa in general and its food waste component is high and increasing with the rapidly increasing population. Survey data (class p1) collected from households, hotels, restaurants, schools and produce markets were analysed using descriptive and logistic regression analyses for insights into the types and amounts of food waste, and respondents' attitudes and practices towards its collection, disposal and alternative uses. Households produce the highest amounts of food waste compared to institutions (hotels, schools and restaurants) and produce markets. In a week, about 96, 72, and 93% of all the respondents in households, institutions and produce markets respectively experienced food waste at least one to three times. On average, with a solid waste collection coverage of 45%, households, institutions and markets in Kampala can respectively supply 680, 80, and 8 t of food waste daily. Moulding, poor food storage, food leftovers, food expiry and excess food produce were the major reasons for condemning food to waste. Over 90% of the respondents recognized food waste as a problem, and as a resource especially for use in livestock feed production, and were willing to consume house crickets raised on feed from food waste. Lower levels of education (none, primary and secondary levels), unemployment, and being divorced at household level were positively associated with recognizing food waste as a resource [X 2 (21, N = 209) = 137.77, p = < 0.0001] and re-use for alternative purposes [X 2 (21, N = 209) = 47.44, p = 0.001] by households and institutions [X 2 (14, N = 92) = 30.97, p = < 0.019]. Majority of the respondents were willing to donate food waste, especially married people and institutions that have been in existence for a period of 5-10 years.

Introduction The global dialogue around policies for health today places much discussion on specifically those living in poverty. Participation is not only promoted in the context of provision and utilization of health services. Advocates also highlight participation as a key factor in the wider context of importance of social determinants of health and health as a human right . Despite the growing interest in the role of participation, there is little concrete evidence that links participation directly to better health outcomes . The absence of this link continues to be a barrier to gain full support of governments, funding agencies and health professionals to promote this approach . The purpose of this article is to review the research that seeks to examine the links between community participation and improve health outcomes in programmes that target poor people. To do this, it starts with systematic reviews and case studies from 2003 to 2013. Relying mostly on systematic reviews, it shows that most research studies view community participation as an intervention and use Randomized Control Trials as the framework to investigate the link. The majority of studies find that such a link is not possible to identify because there is no standard definition of 'community' and 'participation'. Where links are found, they are situationspecific and are unpredictable and not generalizable. It suggests that if community participation is viewed as a process facilitating an intervention rather than an intervention research investigating the link between participation and health status outcomes would have greater validity reflecting how intended beneficiaries see their situations rather than the views of policy makers and planners. Participation of community members in health care is not new. An obvious example is the participation of lay/community people in the provision of care to family and community in their own cultural settings. In addition, community lay people have been involved in the delivery of allopathic health services for the last one and a half centuries. One of the most prominent experiences is the experiment of the Rockefeller Foundation in Ding Xian, China in the 1920s where local people helped deliver services in an area lacking doctors trained in Western medicine . King also records similar experiences in Africa using locals as doctor's assistants in colonial Africa. Worldwide experiences, published by the World Health Organization , argued for the importance of community participation in health care . However, these experiences based on selected case studies produced assumptions rather than evidence of the value of participation. These assumptions included: people will be more supportive of health services if they have been involved in decisions about how services are delivered thus promoting sustainability. People will provide resources to contribute to health improvements in their community. People will change risky health behaviours when they have been involved in decisions about change. People will be empowered by gaining opportunities for knowledge, skills and confidence by being involved in community health . Rifkin has analysed the consequences for building programmes on these assumptions. The results show that many publications present advocacy rather than evidence. With the acceptance of Primary Health Care as the official policy of the member states of WHO in the Alma Ata Declaration in 1978, the importance of community participation entered the global health policy arena. The Declaration stated that health is a human right, that the inequalities in existing health status are 'politically, socially and economically unacceptable' and that essential health care must be made 'accessible to individuals and families in the community through their full participation' . The document highlighted social justice and linked it to equity and participation as principles of PHC. Responding to the call for community participation in the Alma Ata declaration, one of the more immediate actions taken by several governments was the creation of a cadre of community health workers to serve poor rural populations where the majority of the world's population lived. Modelled on China's 'Barefoot Doctors', they were community members trained to provide basic health care and referrals to health care centres. Embedded in the community and supported by the community, it was believed they would lower the cost of health provision. In theory, they also acted as community 'change agents' who would make an impact on poor health behaviours and 'empower' communities to make joint decisions about health care . Answering Alma Ata's call for community participation, CHWs became synonymous with PHC . These expectations proved to be somewhat idealistic. Not only was the idea of CHWs as a means of providing a relatively cheap health service challenged but also the reality of community participation as a guarantee for uptake and support for local health services was not supported . As a result, the concept of community participation became more nuanced. The argument for a wider role for community people in decisions about health programmes resulted in replacing the term 'participation' with 'empowerment' . The Bamako Initiative, underpinned by the LINKING COMMUNITY PARTICIPATION TO IMPROVED HEALTH OUTCOMES move for decentralization of health services from the centre to peripheral units identified the concerns over accountability and governance . The financial crises of the 1980s added discussions about cost effectiveness and sustainability. In addition, the WHO report of the Commission on the Social Determinants of Health and World Report on Primary Health Care highlighted the importance of the social determinants of health and the importance of addressing issues around power and control over decisions about community health and behaviour change. These developments brought issues of empowerment, capacity building of local people, financing and programme sustainability into the dialogue. In summary, the increasing complexity of factors influencing community participation complicated the search for a direct link between community participation and improved health outcomes. This was particularly true in the health field where the dominant paradigm, exemplified by RCTs, examines phenomena in a linear, causal relationship and explains events that do not fit into this framework as confounding variable. --- Methods This article updates an earlier review undertaken by Rifkin . It is based on a systematic search of PubMed and Google Scholar for relevant articles published between 2009 and 2012. It mainly relies upon a review of published systematic reviews in English on the topic . Key words included community participation, CHWs, community health committees, community accountability, community engagement, participatory learning and action. Inclusion criteria were evidence of community participation in the context of health care delivery including services and promotion where health professionals have defined the community's role. The criteria also included reviews that examined programmes where professionals designed the programme and mobilized communities to take up the benefits. This approach has been identified as 'induced participation' in a study by the World Bank asking 'does participation work?' . It does not include research for health where remits involve communities as collaborators in research for health care improvements . --- Reviews that examine the role of the community health worker In the period that followed the Alma Ata declaration, CHW programmes proliferated. After a hiatus of interest in CHWs for about 20 years, the new concern about the crisis in human resources for health that highlighted the dismal lack of health providers especially in poor rural areas in Africa due to the HIV/AIDs epidemic resulted in the expansion of CHW programmes. Several reviews of CHW programmes have recently been published. Bhutta et al. 2010 examined CHW programmes for the WHO Global Workforce Alliance. The review concentrated on the performance of CHWs to deliver credible health care interventions. However, despite the recognition that community participation was a key element of successful programmes, Bhutto and colleagues clearly state: 'Importantly, community ownership and supervision of CHWs is a key characteristic which is insufficiently described and analyzed in available literature' . In a more recent review by Perry and Zulliger , the authors provide evidence of performance of CHWs and make a series of recommendations about the technical and structural support for CHWs. However, they note 'there are very few studies that give 'voice' to CHWs and provide an opportunity to learn about their views regarding the challenges they face in their work and how programmes could help them to be more effective . These conclusions are confirmed in a review done by Naimoli et al. who looked at 18 programmes for the United States Agency for International Development. Their data shows that while community involvement is considered a key component of programme design there was little participation in the design, recruitment and implementation in the programmes . The focus on health outcomes is repeated in the Earth, Inc. Report arguing for expansion of CHWs. While noting the importance of community participation these reviews views fail to take up the challenge of examining its contribution. Reviews that seek evidence of a direct link between participation and improved health outcomes related to disease control and improvements in maternal and child care Motivated by the search for replicable designs and the search for funding, researchers have increasingly sought to find evidence of a causal link between community participation and improved health status. Not surprisingly, strong efforts for the search have been made in the area of communicable disease control. For example, a systematic review of control of Chagas disease concludes that participation enhanced the control of the disease but further evidence was necessary . Concerning the examination of the detail that describes participation, the authors say For instance, we found that most community-based experiences in Chagas disease vector control are merely, utilitarian, with little or no participation of the community in design, planning and evaluation of interventions. Effective involvement of all stakeholders along the whole process would no doubt foster true empowerment, and this could in itself result in improving health and living standards . No evidence is given to support this statement. A review by Atkinson et al. responds to the lack of investigation into the wider role of the community by a systematic review examining communicable disease control in low-and middle-income countries using malaria as a case study. Out of 60 studies meeting criteria standards, only 4 addressed the relationship of disease transmission. The review shows that community participation has played a key role in disease control and elimination in many countries. However, the exact nature of this role is hard to define. The reason, the authors state that the potential of community participation has not been realized is that there is a lack of definitions for 'community' and 'participation' and insufficient investment in the 'peoples component' of the programmes. Research undertaken at the Institute of Child Health, UK, looks at a meta-analysis of seven RCTs in Malawi, India, Bangladesh and Nepal . The intervention was using women's groups practicing Participatory Learning and Action to improve birth outcomes. Seven trials met the inclusion criteria. Meta-analyses of all trials showed that exposure to women's groups was associated with a 37% reduction in maternal mortality , a 23% reduction in neonatal mortality , and a 9% non-significant reduction in stillbirths , with high heterogeneity for maternal and neonatal results . In the meta-regression analyses, the proportion of pregnant women in groups was linearly associated with reduction in both maternal and neonatal mortality . A subgroup analysis of the four studies in which at least 30% of pregnant women participated in groups showed a 55% reduction in maternal mortality and a 33% reduction in neonatal mortality ) They conclude that women's groups are both cost-effective and a realistic way to reduce maternal deaths and improve birth outcomes rapidly and on a large scale. Marston et al. investigate the effects of community participation on improving skilled care for maternal and newborn health. From the search of 11 databases with following up secondary references, they found 10 interventions. They defined interventions as getting people together to think and talk about health problems and services and having people act upon or having outsiders help people to act upon what people said. Looking at community participation as an intervention, from the evidence they state that there are few high quality quantitative studies, none of which answer the question of why interventions succeed or fail. They conclude that a qualitative research component and studies of complex interventions as part of the RCT would assess potential of generalizability and help understand the hard to measure social/ political effects of participation. Preston et al. examine the literature to seek evidence of the link between community participation and improvements in rural health outcomes. Of the 689 articles identified, 37 met the qualification criteria. Their review found little evidence of a direct link. However, they state lack of evidence did not mean lack of effect. They argue that it is necessary to improve our understanding about community participation in terms of the expectations of time and financing and tools to measure and understand participation in a health development context. --- Reviews that seek evidence on community participation and improved health systems including accountability With the recognition in the 1980s that improved health status not only depended on disease control but also on the systems that delivered health care, interest began to focus on the importance of actively involving the beneficiaries of care in decisions about the provision of that care. With a focus on developing countries, Mubyazi and Hutton have reviewed the published and grey literature about community participation in the context of health planning, resource allocation and service delivery. They highlight the fact that lacking a standard definition, community participation in programmes has no common approach. Eighty-five articles met the criteria for review. Of these 37% were experimental, 55% were observational and exploratory, 42% were reviews and/ or discussions. They conclude that the contribution of community participation to improving health depends on a wide variety of factors including system factors and socio-cultural factors. They point out that most authors focus on one dimension of community participation such as mechanism for community expression for public priorities. Seeing participation as a solution to one particular health problem without considering other systemic factors also limits the assessment. The review illustrates and the authors highlight that there is the lack of data about a comprehensive and generalizable approach to community participation and its relationship to improved health. McCoy et al. investigate the contribution of health facility committees, a mechanism seen to give 'voice' to beneficiaries in the delivery of the care they receive. They also discuss the frustrations from the inability to give standard definitions of 'community' and 'participation'. They identified only four cases rigorous enough to provide robust data for analysis. From this data, the authors found that it was not possible to confirm external validity. The outcomes depend on the process and the interaction between the intervention and the context. Molyneux et al. review the literature examining community accountability at the peripheral health facilities. They identify 21 articles from low-and middle-income countries with robust data. The most popular mechanism for community accountability was committees followed by groups, most popular women's groups. They identify several key factors that related to strong accountability mechanisms. The success of these committees depended on how and why they were selected, the relationship between committees, groups and the health workers and managers and provision of support including resources by local and national governments. All these factors are processes on which community participation depends. They are context and content specific. --- Reviews that seek evidence of community participation and health promotion Community participation, or community engagement as it is often called, has been part of the policy of the United Kingdom government since the 1970s. It is intended to involve communities in order to change poor health behaviours by involving local people, motivating better behaviour and defining how government can support their choices. In their review of this policy, Evans et al. note that the policy has been followed erratically over the past 40 years. They found 2155 documents. In their analysis, they highlighted the lack of RCTs available and relied on systematic reviews that used qualitative LINKING COMMUNITY PARTICIPATION TO IMPROVED HEALTH OUTCOMES research. Only very few reviews met their quality criteria and only four reported on the process of participation and communities' perception of quality and impact of participation. Their main finding was there was very little evidence of a direct link between participatory approaches and a 'noteworthy' impact on health and social outcomes. Milton et al. did another study on the same topic and came to a similar but more nuanced conclusion. On the basis of 13 studies that were robust enough to meet their inclusion criteria, they found no evidence of positive impacts on population health or quality of services but found that initiatives did show a positive impact on housing, crime, social capital and community empowerment. They also point to the need for methodological developments that enable researchers to identify more robust evidence to assess multi faceted social interventions. --- Discussion In summary, the reviews identify several common issues that challenge the investigation of a direct link between participation and improved health status. These include the lack of common definitions for the terms 'community' and 'participation', the recognition of a key role of community participation but the lack of conceptual and practical frameworks to articulate this role, and the inability to disaggregate the contribution of community participation to health from other community development improvements. The common theme is that the frameworks that have been used do not allow the results to be generalizable. Evidence shows that outcomes are determined by context and context varies. Adding a qualitative component to the research design does not address the challenge of making the findings more robust. Qualitative data only defines more clearly the importance of context and situation. In the field of health research, intervention studies are dominant. They are designed by health professionals and seek to test a hypothesis by introducing interventions and evaluating outcomes. Based on assessments of clinical trials, the RCTs set the standard. This approach has also been used to study population health. Community participation is the intervention. The hypothesis is that this intervention will improve health outcomes. However, the evidence suggests it is not possible to adequately test this hypothesis. Sanson-Fisher et al. have reviewed the complications of using RCTs for evaluating for public health outcomes. They argue that population-based interventions cannot be evaluated in this framework for a number of reasons. These include issues around population validity, time for follow-up, external validity, contamination of study population, cost, ethical and informed consent and inhibition to develop innovative research questions. The case studies in this review all explicitly or implicitly use the RCT framework in terms of their research question. They illustrate the limitations of RCTs. Two most explicit examples are those concerning the contribution of CHWs and the systematic review of the participatory women's groups to improved birth outcomes. Concerning the former, although the reviews recognize the critical role of community participation, they focus on the causal link between service provision by CHWs and improved health status. This focus takes a mechanistic, reductionist approach to the values of CHWs. Although the reviews highlight the challenge of questions around replication, financing, sustainability and ultimately community ownership, they do not take up this challenge. Concerning the latter, as Victora discusses in the International Journal of Epidemiology, women's groups are not aimed at specific changes in health status but rather at raising the consciousness of people to take action on their impoverished lives through transforming their circumstances through action and change of power. The causal chain of poverty and transformation is not caught in a RCT. Recognizing the limits of RCTs, important attempts have been taken to modify the approach. One example documented by the Medical Research Council in the United Kingdom recognizes 'complex interventions'. It provides guidelines for researchers involved in non-experimental studies and interventions that go beyond delivery of health services to understand constraints on evaluation designs and to assist users of studies to assess their in terms of methodology and practical considerations. The Rockefeller Foundation of the United States has also taken up the challenge by defining and examining indicators as interventions . The authors argue indicators are diagnostic tools for identifying problems and needs, measuring for performance, building ways for awareness-raising and public advocacy and instruments of change. While both of these approaches seek to address concerns about the use of intervention studies they still see communities as the object not the subject of the programmes. In the field of evaluation of public services, Pawson et al. have put forward the concept of realistic evaluations. They outline a step-by-step framework. Step 1: outline the theoretical framework by defining the assumptions about how the intervention is seen to work and its expected impact. Step 2: look for empirical evidence to test the framework in terms of support, contradiction and/or modification. Step 3: combine the theoretical and empirical evidence and focus on the context in which the intervention is applied, the mechanisms that makes it work and finally the outcomes. Specifically in the health field, community-based participatory research and participatory research address important elements of realistic evaluation by involving community members in designing, implementing and evaluating specific health interventions. However, all these approaches are conceptualized in the context of intervention studies. Although recognizing the importance of participation as a process, to date they do not explain how these processes develop community ownership, a key challenge identified by Bhutta et al. in the context of CHWs. At present, health professionals make decisions about the outcomes that are to be achieved. Trickett et al. , state this research raises the challenge that local knowledge and influence is being carried out by science devised by professionals outside the community. Based on the findings of this article, it can be argued that a new framework is needed to understand the value and challenges of community participation to improved health outcomes. This does not suggest that an intervention research framework has failed to help us confirm the value of community participation. Many of the reviews, as noted above, have identified health improvements as a result of participation. Nor does it suggest a rejection of quantitative data to document improved health status related to community participation. Measurements are critical to confirm change and improvements. Non-Government Organizations and the governments of India and Brazil have national programmes where community participation is key. They have evidence of health improvements. The challenge is to define exactly how communities have benefited and why they have benefited. In this quest, a research framework that views community participation as a process rather than an intervention is more useful. Merriam Webster defines intervention as the act or fact or a method of interfering with the outcome or course especially of a condition or process . It defines process as 'actions or events leading to a result' . In health improvements, an intervention is an act or method that seeks to encourage individuals and/or communities to accept a change in attitudes and behaviour to improve their health. A process is the actions over time that allow acceptance of the intervention. A number of researchers have taken this approach to investigate participation as what supports the uptake and sustainability of a concrete intervention . Butterfoss presents a framework to evaluate community participation as an intermediary step to health and social change. She gives tools to examine the relationship between community building and organizing principles and health outcomes. However, the evaluation framework is based on measuring participation and is, thus, a reductionist approach. It does not take into account the specific context of the process or highlight the nature of change over time. Butterfoss recognizes that measurements alone are not enough to ensure progress. Critical is how communities are defined and who represents them. The framework most used was developed by Rifkin et al. and visualizes the process of community participation as a 'spidergram'. It identifies five factors that influence community participation , places each on a continuum with wider participation at one end and narrow at the other, assigns a mark on the continuum for each factor, links the continua at the end of narrow participation and connects the marks. By assessing these factors at different times during a programme, planners and managers can see if participation has increased or decreased. A modification of this framework by Draper et al. replaces the continuum with mobilization at one end and empowerment at the other. This framework has been used to assess participation in relatively small health programmes. It allows programme planners and managers to document changes in community participation over time and make programme adjustments. It also allows the intended beneficiaries to express their views about participation in the community health programme and dialogue with managers about changes. Case studies using the framework include: investigating community participation in a Heart Health Program in British Columbia ; assessing rural health trusts in New Zealand ; examining CHWs in Cambodia ; supporting dengue control in Cuba : reviewing the contribution of community participation to 23 health programmes in Muldersdrift Health and Development Programme in South Africa and assessing Safe Motherhood Health in Myanmar . The framework defines the process in specific situations related to history and culture of the community. To identify what aspects of the process might be generalizable more research is needed. This research needs to focus on the social determinants of health as discussed below. Considering participation as a process is not merely adding a qualitative component to supporting a mixed methods approach to research or using tools to measure peoples' behaviours and beliefs. It also includes examining the social, economic and political context over time. It includes measurements but also focuses on a holistic analysis of a specific situation. From a collection of a wider range of data, communality through comparison can be identified and the search for replicable, generalizable factors can be investigated. It is also necessary to investigate the assumptions behind the contribution and to develop frameworks for examining these assumptions. A first step is to reframe research questions to identify community participation as a process and recognize this process is a reflection of the context in which it takes place over time . A second step is to identify and examine in detail common domains that influence these processes. Evidence is available to start this identification. Domains include leadership, capacity building, resources mobilization and management . A third step is to recognize that participation by its nature must deal with issues about power and control. Research needs to address this issue to understand the link between participation and improved health outcomes. --- Conclusion Community participation is increasingly recognized as key to improving and maintaining interventions that improve health outcomes. To date, community participation has most often been seen as an intervention to improve health outcomes rather than a process to implement and support health programmes to sustain these outcomes. To understand the relationship between community participation and improved health outcomes, new frameworks are needed. Examining community participation as a process and dealing with critical issues around empowerment, ownership, cost-effectiveness and sustainability of health improvements would move this dialogue further. --- Conflict of interest statement. None declared. --- Appendix Table A1.

As a key principle of Primary Health Care (PHC) and Health Systems Reform, community participation has a prominent place in the current global dialogue. Participation is not only promoted in the context of provision and utilization of health services. Advocates also highlight participation as a key factor in the wider context of the importance of social determinants of health and health as a human right. However, the evidence that directly links community participation to improved health status is not strong. Its absence continues to be a barrier for governments, funding agencies and health professionals to promote community participation. The purpose of this article is to review research seeking to link community participation with improved health status outcomes programmes. It updates a review undertaken by the author in 2009. The search includes published articles in the English language and examines the evidence of in the context of health care delivery including services and promotion where health professionals have defined the community's role. The results show that in most studies community participation is defined as the intervention seeking to identify a direct causal link between participation and improved health status modeled on Randomized Control studies (RCT). The majority of studies show it is not possible to examine the link because there is no standard definition of 'community' and 'participation'. Where links are found, they are situationspecific and are unpredictable and not generalizable. In the discussion, an alternative research framework is proposed arguing that community participation is better understood as a process. Once concrete interventions are identified (i.e. improved birth outcomes) then the processes producing improved health status outcomes can be examined. These processes may include and can lead to community uptake, ownership and sustainability for health improvements. However, more research is needed to ensure their validity.

Introduction COVID-19 emerged as a major threat to global health . Every country in the world made drastic decisions to reduce the mortality rates associated with this virus . These decisions range from those that limited the freedom of mobility of millions of citizens , such as the total lockdown ordered by world governments at the beginning of the pandemic ; restrictions on access to events or services for people who were not fully vaccinated ; restrictions on the use of educational services or cultural spaces for collective leisure . Faced with the risk of collapse for the Colombian health system, the National Government decreed a state of national emergency , which, among other extraordinary measures, decreed a national lockdown called "obligatory preventive isolation" . This lockdown lasted 159 days, one of the longest in the world . Basically, the APO restricted citizens' national mobility and circulation, with some exceptions for basic and essential services, such as police, medical-sanitary, public espaciotemporal que define la dinámica de los hurtos en la ciudad de Pereira y estos patrones se pueden explicar desde la teoría de los entornos generosos del crimen. --- Palabras clave: Hurto , patrones delictivos, Gobierno . Redes, Colombia . --- Resumo A contingência provocada pela COVID-19 deu origem a múltiplas interações sociais para as quais nem os governos nem os cidadãos estavam preparados. As medidas restritivas de mobilidade impostas pelo governo nacional produziram uma série de mudanças não apenas na dinâmica social e nas transações legais, mas também no contexto criminal. O objetivo deste estudo é compreender o comportamento espaço-temporal do roubo na área metropolitana de Pereira, Colômbia, e comparar este comportamento em tempos normais e em tempos de pandemia. Os dados foram obtidos consultando a aplicação Siedco para a cidade estudada na janela de tempo 2019-2021. A análise espacial foi realizada utilizando a técnica conhecida como "identificação de padrões para redes de eventos espaço-temporais ." As evidências empíricas observadas nos permitem concluir que existe uma configuração espaço-temporal que define a dinâmica do roubo na cidade de Pereira e estes padrões podem ser explicados a partir da teoria dos ambientes de crime generoso. --- Palavras-chave: Roubo , padrões de crime, Governo . Networks, Colombia . health, the trade of basic goods, and public transportation . Despite the APO and the clarity as to which individuals were exempt from the mobility restrictions, criminal networks continued to operate in Colombian cities . Theft and other crimes, like other sectors of the economy, transformed and adapted to the reality of a civilization in full pandemic. Some authors called this adaptation the "new normality" . Although the presidential decrees that regulated citizen mobility in the pandemic did not include non-essential personnel in the provision of services, the streets of Colombian cities clearly demonstrated that highly socially vulnerable people such as street dwellers or Venezuelan migrants did not comply with national regulations, due to the particular condition of their social group . Similarly, offenders of crimes such as theft were not locked up in quarantine for long either . Above all, because offenders of this type do not have a financial strategy and therefore no money reserves, and they live from hand to mouth, i.e., from low-paying informal jobs or illegal actions such as theft . This study focuses on describing the behavior of thefts during the pandemic period and comparing it with an equivalent time window, but without mobility restrictions. To this end, the Siedco1 database of the Colombian National Police was used and the data were analyzed using the pattern identification for space-time event networks technique and a sociological analysis of crime-generating environments. This study attempts to answer the following research question: Were the space-time dynamics of theft in Pereira altered by the mobility restrictions applied during the pandemic? --- Literature review and theoretical framework --- Sociology of place and environmental criminology It is assumed that crimes do not occur at random. That is, even if they arise from opportunity, they always involve a series of repetitions, rituals, and planning, which leads to the assumption and affirmation that chance is not a structural element of criminal action. Clarke indicates that individual criminal behavior is influenced by a physical environment that provides opportunities. Crimes are committed by people and occur in specific places. Hence, it is important to understand how places are configured from a social perspective. The impact of the physical environment on human behavior has been extensively studied . Barker characterized the ecological environment as an objective reality that influences human behavior. The author also pointed out that behavioral environments have permanent patterns of social activity that persist, even when the participants change. Along the same lines, Chapin showed that people tend to act in certain ways in a given urban environment. The places where crimes occur also have a particular social configuration. The study by Tita et al. highlights that place is an important factor for criminal gangs. The authors use the term "established spaces" to identify those places to which criminals confer meanings and where they even physically and socially transform the places where crimes take place. The fact that criminal subjects control a space in which they frequently commit crimes, highlights the role of the social context and allows us to analyze the social relations that take place in these locations. This study is situated in the field of environmental criminology . The research question is approached from the interpretative framework of the association between the spatial and environmental context in the occurrence of a particular crime such as theft . Environmental criminology critically reviews the configuration of illegal activities based on their concrete spatial relationship . This interpretive approach is based on urbanism and human ecology . It studies the link between place, space, and role, from the interaction between victims and offenders . Environmental criminology critically analyzes space as a dynamizing element of crime. Crime benefits from certain places, as criminals gravitate to, control, and operate the most lucrative places to ply their trade . Conversely, certain places are particularly challenging and far removed from criminal interest, as they can be highly guarded or places that do not contain a high payoff . Several studies using environmental criminology found that this approach provides a general understanding of a criminal phenomenon. For example, Norza Céspedes et al. , found that spatial-environmental variables were the most determinant when analyzing homicides in Bogotá, Colombia. Sánchez and Serrano , on the other hand, found that the criminal dynamics of a neighborhood in Alicante, Spain, were associated with the dynamics of occupation and land use, such that the most vulnerable sectors of the neighborhood historically concentrated the highest number of reported crimes. Along the same lines, the study by Pratama et al. , identified the causes of increased thefts in Lumajang district, Indonesia, during the COVID-19 pandemic. --- Environmental munificence In accordance with Becker, in this study, we explore the idea that theft as a crime occurs from the perspective of rational economic activity . Becker divided his analysis into two aspects: in the first he speaks about efficiency in the allocation of resources and, in the second, about individuals' valuation and decision to carry out an activity. For Becker ), a subject commits a crime if his utility is outweighed by the illegally obtained asset, accounting for the use of resources such as time, his body, his learning, and the technologies that mediate the criminal activity. From Becker's perspective, a criminal becomes a criminal not only because of his basic motivation to commit a crime, but also because he applies reasoning that weighs up costs against benefits. Although rational choice is supported by several empirical studies that have statistically and argumentatively proven its relevance for criminological analysis . in some cases, it does not always successfully explain criminal phenomena. For example, Herrnstein and Murray argue that beyond rational decisions or relationships with cognitive ability, crime is explained by the social conditions surrounding criminal subjects. For this study, it is assumed that individuals who commit theft use cost-benefit reasoning, but also understand the resources offered by the environment. And, in this sense, place becomes fundamental for the commission of crimes. From a criminological and sociological perspective, rational choice theory can be said to be supported by two theories: the necessary condition theory and environmental munificence theory . The necessary condition theory is concerned with specifying the essential elements necessary and collectively sufficient for a crime to occur, in this case theft. Cohen and Felson proposed that the necessary conditions for a criminal event involve a motivated offender, a target, and the absence of a security guard. If any of the above are not present, it would be assumed that there would be no crime because of the high costs involved. For example, there would be no crime if there were no potential victims with valuables, or if the security scheme of a place is of a very high standard, or if the offender has other activities that are more lucrative and pose less immediate physical risk. Environmental munificence is based on the concept of the abundance or lack thereof of resources in an environment , which has been used to explain, from an economic perspective, that places offer competitive advantages for the development of various economic activities. Environmental munificence is the scarcity or abundance of critical resources needed by firms operating within an environment . Environmental munificence explains the concentration of different productive sectors at different geographic scales. A study by Restrepo , offers a conceptual scheme that allows the analysis of the environment of companies based on the competitive advantage they acquire according to the place where they are located. The concept of "environmental munificence," allows us to analyze the behavior or establishment of illegal activities in a specific location . Environments that are munificent for crime allow us to explore the way in which the sociohistorical configuration of a place guarantees success for the commission of crimes. This theory sheds light on the reasons behind there being a concentration and territorialization of crime in certain parts of cities. Such a concentration of crime is due to the attributes offered by a particular location. For example, the places in which drug trafficking or theft occur differ not because of their spatial location, but because of the conditions that these places guarantee to criminals: concealment, potential victims, state neglect, or legitimacy conferred on criminals. Studies such as the one by Beltrán and Salcedo-Albarán analyzed how Colombia has provided a munificent environment for drug trafficking, and concluded that the social configuration of locations explains Colombian drug traffickers' success in consolidating their position in the global market. Among the elements that they consider to be generous to drug trafficking, the authors find that geographical, cultural, and social factors have allowed this illegal activity not only to coexist with the Colombian legal framework, but even to become legitimized in the places where it has co-opted the Colombian state. Similarly, in his study of the territorialization of drug trafficking in Medellín, Aguilar finds that the social construction of Medellín as a place has allowed, catalyzed, and guaranteed that drug trafficking exists as a macro-device that orders resources, spaces, and actors. Factors such as criminal apprenticeship have allowed the accumulation of experiences and technologies for the use of violence. Territorialization and its respective normative and punitive control, as well as the permissiveness and acceptance of the different socioeconomic classes, are explanatory factors that explain the success of drug trafficking in this Colombian city. --- Data and methodology --- Case study and nature of the study This is a case study , which was chosen in order to capture the complexity of an individual case with two specific contexts: the behavior of thefts as a social fact located in a specific space-time, and the impact of mobility restrictions dictated by the Colombian government in the context of the coronavirus pandemic. Pereira was chosen for the study based on two parameters: its strategic location in relation to the three large cities in the country that make it an attractive city for national investment and also for various criminal organizations ; and the need for a systemic analysis that explains the dynamics of high-impact crime . This is a mixed study , combining three types of research: exploratory, descriptive, and geospatial. . --- Data The dataset comes from the Criminal Information Management Group of the Dijín with the supervision of the Crime Observatory of the Metropolitan Police of Pereira, which is the criminal investigation area of Colombia's National Police responsible for collecting and analyzing crime-related information . This dataset contains the information on thefts registered in the city of Pereira for 2019-2021. It should be clarified that these time windows were defined based on the mobility restriction dictated by the Colombian National Government that started on March 25, 2020. This period was divided into two temporary windows: 25/03/2019 to 24/03/2020, and 25/03/2020 to 24/03/2021. The dataset contains 5,903 records, each with 24 variables describing the crime of theft from persons. This information was collected in the field by personnel of the Colombian National Police, who record the theft by means of minutes . Two computer tools were used to classify and process the information. ArcMap 10.7.1 was used for geographic information processing. All spatial and temporal statistical analyses were performed in Phyton using the Geopandas, Shapely and Scipy.spatial packages. --- Pattern identification for space-time event networks The Ipree technique used for many areas of research associated with crime, ecology, and epidemiology, among others was also applied in this study. The space-time interactions of events, the manner and regularity in which they are grouped or the distances between these groupings are important to understand the phenomenon under study, in this case theft. Studies of this type have analyzed various attributes of crime. For example, Hegemann et al. reconstructed gang rivalries in East Los Angeles with an agent-based model that used geographic information and simulated confrontations between these gangs, based on the dynamics of their movements. The study provided insight into the gangs' patterns of spatial occupation and confrontations. Another study, conducted in three Colombian cities by Rentería-Ramos and Jiménez-García , used topological networks and found that homicide in these three cities had a morphological configuration, which was useful in explaining the space-time dynamics of homicide from a historical perspective. It also made it possible to affirm that homicide does not occur randomly in space. For this study, networks were used to analyze the patterns of thefts embedded in space-time. Based on the metrics and topological properties of the thefts, it is possible to construct approximations of the co-occurrence, displacement, and dependence between different theft events . This made it possible to compare the existing patterns before and during the pandemic. The applied Ipree technique , introduced an innovation when compared to the dynamics of topological networks used in other studies . This innovation is the random generation of networks that preserve the topology of the data and vary according to temporal scales, and is in line with that implemented by Davies and Marchione who had already constructed time series of events based on temporal divisions into spatial strips and distances. This innovation, known as the "random network generation mechanism" , maintains spatial locations, varies the order of occurrence of events, standardizes results to prevent motif counts from being masked by the number of links, and permits a comparison of networks over time . This allows space-time patterns to be defined more accurately. Comparing theft behavior before and during the pandemic, revelaed which places in the city, despite the mobility restriction and reduction of possible victims , continued to maintain a dynamic of thefts. According to the above, it can be deduced that these places concentrate characteristics that allow them to be identified as munificent environments for crime. --- Basic explanatory elements of Ipree A space-time point process is a random collection of points, where each event is associated with a place and time. A graph is a collection of interconnected events or a configuration of relationships between events . A graph G is a mathematical structure composed of two sets: a set of nodes, V, and a set of links or edges E, such that each edge element e k = ∈ represents a connection between two elements v i , v j ∈ V . A graph is directed if each edge ek is associated with a direction, i.e. , is different from . A directed graph without a path starting and ending at the same node is called an "open cyclic graph." If a weight is assigned to each node or edge of a graph, it is called a "weighted graph." . A network mofit is a subgraph that appears more frequently in a given network compared to general random graphs . An event network is a graph in which its nodes are events and some links are placed between close pairs, i.e., events close in space . Two properties of mofits are important for the present study: T number of events is a random variable, and therefore so is the number of nodes, and T links depends on the location of events, and is the reason for which the event network does not admit links between distant events. This makes it clear that a sequence of random events Z over time was called a "time series" and denoted as {Z t , t ∈ T ⊂ R}. Thus, {G t , t ∈ T} is a time series of event graphs where each Gt is an event graph itself. --- Step by Step The purpose of the study is to understand how mobility restrictions affected the dynamics of theft and how these dynamics are configured in the city of Pereira. Capturing the interactions between endogenous and exogenous criminogenic events is very useful in evaluating whether these behaviors are conserved in space, time, or both. In this sense, the most appropriate model for this purpose is the proposal offered by Forero et al. , to analyze the configuration of space-time clusters based on event networks, and through subgraphs to evaluate the dynamics of criminal events; as well as the way in which the graphs that dynamize the emergence of these clusters are assembled . The first step consists in the construction of event networks, following the definition of Forero et al. , where a network, according to Wasserman and Faust , Newman and Marin and Wellman , is defined by F=, where V is the set of vertices, v ∈ V , and each v e is the geographic location of the criminal event. E , on the other hand, is the set of edges, and for this research e ∈ E , where e is the temporal relationship between the events . Also, given that time is a determining factor in this model, the order in which events occur is, therefore, ≠ , which leads to the conclusion that the network connectivity is directional. The network construction algorithm is shown in Figure 1. Once the set of nodes has been defined , the next step is to define the special component or spatial units; in this particular case, spatial samples of radius are defined . In other words, the process consists of dividing the territory into small areas of radius , taking into account each of the criminal events considered for this research as a centroid. An important aspect to be considered in constructing the networks is to accurately define the value assigned to , because they can hide or underestimate the incidence of criminal events in the patterns that energize the formation of space-time clusters. To solve this problem, we considered the principles of geographical juxtaposition of crime based on the CPTED [crime prevention through environmental design] theory by Cozens and Love , which Forero et al. incorporate in their research and categorize into four spatial patterns. However, for this case, only three of these will be used: micro , proximal , meso . In accordance with the above, the set D ∈ d , considering the following distances to capture the micro, proximal and meso patterns are D = {10,100,1.000} . Despite this configuration of the model parameters, adjusted with the criminogenic theories, this algorithm can yield overdimensioned results due to the phenomenon of distances traveled. An example of this phenomenon is as follows: the pattern that is detected with a d =10 m, is embedded in a d=100 m , y and this, in turn, in d=1.000 m. On the other hand, the size of the network grows as the value of increases, which makes it very difficult to obtain a statistically significant pattern, reflecting conserved quantities , which in turn are robust. Davies and Marchione and Forero et al. defined that the best way to analyze these networks is from the perspective of assembling subgraphs or motifs. Motifs, according to Davies and Marchione , Atluri et al. and Pasquaretta et al. , are small subgraphs that repeat in a network, and their frequency, besides reflecting some connectivity patterns, are elements that have a low entropy in the data set that gave rise to the network. To solve these conditions, the Ergen algorithm by Forero et al. , was incorporated: 1. Motifs detection using the model by Paranjape et al. , privileging some shapes applied to crime events established by Davies et al. and Forero et al. , to find the micro, proximal and meso space-time patterns of Cozens et al. . 2. To avoid overlapping networks as the distance d is modified, a permutation of the network adjacency matrix F is calculated, 10,000 networks are randomly selected and the motif detection algorithm defined in is applied. 3. Once the motifs have been defined, the next step is to count the subgraphs, and according to their frequency and co-occurrence, their importance in the configuration of the space-time pattern is weighted. 4. Finally, a statistical significance test is performed on the results through the Z-score, to evaluate whether the form or motifs found are a subgraph that can explain the space-time dynamics of the criminal event. 5. An average is calculated from all the shapes found, and steps to are repeated n times, in this case according to Forero et al. , n = 100.000. The metropolitan area of Pereira is located in central-western Colombia , strategically situated in the center of Colombia's three economic and political axes: Bogotá, Medellín, and Cali. This metropolitan area is made up of three municipalities: Pereira , Dosquebradas, and La Virginia, all belonging to the department of Risaralda, and has a population of 741,534 inhabitants . The metropolitan area of Pereira is characterized as a place where the goods and services markets of the country's three main cities converge . It has historically constituted an axis of local development based on the trade of goods and services . In addition to having consolidated a textile and coffee industry that brought wealth flows . This makes this metropolitan area highly dynamic economically and, therefore, attractive for capital investment. --- Results --- Theft dynamics in Pereira The above conditions, which are attractive for economic dynamics, are also attractive for criminal contexts, and, like many of the country's cities, Pereire too has a complex problem of organized and non-organized crime . MA-Pereira registers high homicide rates each year , as well as other high-impact crimes such as theft . Although MA-Pereira has a very active crime dynamic, few studies have attempted to analyze these dynamics . Most of these studies are descriptive, and although their productions contribute to an explanation of the criminal issue in the city, it is true that the reflections in the light of criminal theory are few . This leaves authorities and civil society with few alternatives to protect themselves or to make progress in finding solutions to such circumstances. A total of 28,211 thefts were recorded in Pereira over the last ten years, an average of 2,821 thefts per year, with an average rate of 360 thefts per 100,000 inhabitants . Figure 4 illustrates a decrease in the number and rate of thefts during the pandemic , which then recovered when citizens were allowed to move around the city again. However, it should be noted that this reduction was not significant, considering that mandatory preventive isolation in the city kept a large part of the population out of circulation. In sum, despite the crime prevention and coercion strategies implemented by the authorities during the various city and metropolitan area administrations, the city of Pereira continues to have an active and constantly rising theft dynamic. The city's economic and social context makes it attractive for this type of crime. Below, we focus on two specific spatial windows and discuss these theft conditions and socially configured environments. --- Theft during and after APO The pandemic affected social interaction in all its aspects . It modified routines, especially those associated with mobility and the social construction of space. The Government of Colombia implemented a series of measures that restricted social contact: APO . As social contact was avoided, virtual mediation replaced these contacts and gave rise to new forms of social interaction, adapted to the global scenario that the planet was reproducing. Virtuality made it possible to continue such contacts. Birthdays, religious celebrations, registry and notary acts, and even many jobs took place remotely, supported by the technological devices and platforms that allowed this connectivity. At the same time, the trade of illegal goods continued with the same logic. Drugs and other illegal goods were acquired remotely and delivered to the user's home. While this was not new, the quantity of transactions was. Although virtuality made it possible to adapt to the new reality and its restrictions, it was impossible for many sectors or activities to comply with or perform their tasks. Naturally, the medical emergency service , food production and sales, police surveillance services, and transportation services continued without mobility restrictions. Something similar happened in the illegal context, and the thefts are proof of this inability to adapt, above all, because theft essentially requires a perpetrator who conditions the relationship with the victimizer, and who takes possession of the goods of another. The dynamics of theft varied with the APO measures. As in other contexts studied by researchers, theft in Pereira decreased . The fewer the people on the street the fewer people who are likely to be victims of theft . Comparing pairs of months , it was found that the months with greater mobility restrictions saw the greatest decreases in the number of thefts. April and May recorded the largest decreases: April with 74.0 % reduction and May with 57.8 % . Conversely, in months where mobility restrictions allowed more people on the street to circulate with social distancing, even more thefts were recorded than in non-pandemic times. For example, January 2021 recorded an increase of 26.0 % compared to the previous year . Another way to measure the impact of APO on this crime sector is the modification of the patterns of theft and offender dynamics on temporal and spatial scales. --- Space-time patterns The theft dynamics in the metropolitan area have historically been concentrated in four axes that coincide with the most dynamic centralities in terms of commerce and services . These four axes are known as Downtown Pereira ; Cuba, the most populous neighborhood in the Eje Cafetero ; and two axes in the municipality of Dosquebradas, known as Santa Monica-La Pradera and Guadalupe, which coincide with being the places with the highest land use value in the municipality adjacent to Pereira. Figure 5 shows that there was a decrease in the number of thefts in the city due to mobility restrictions; however, the concentration of these thefts continued to be in the same places, and a corridor was even formed connecting the theft dynamics of Downtown Pereira with the sectors in Dosquebradas of Santa Monica-La Pradera and Guadalupe . The figure also shows a change in the theft dynamics in the center of the city, with a decrease in the intensity of thefts in the university sector , but at the same time, the theft radius increased in central sectors of the city, reaching even as far as the Jardín and Maraya sectors . The maps in Figures 6 and7 show the concentration of thefts in the entire MA-Pereira and how the pandemic modified this concentration, excluding areas of the city, such as the universities, hat were affected by the restriction, but moving to residential areas close to the center, as is the case for Jardín-Maraya and the residential area in Dosquebradas that was created as a corridor between the Pereira-Guadalupe Center . Although these graphical results suggest that APO did have an impact, it is not possible to measure the socio-spatial-temporal influence of these measures. Figure 8 shows the entire network of events that were configured according to the methodology used, so that the impact of the restrictions so as to better explain the temporal and microspatial dynamics. In this sense, the theft events produced a highly assortative network, i.e., it is modular, which showed how the events are articulated to create the space-time clusters shaped by the theft dynamics . Although the network reveals that there are indeed clusters of events occurring in space-time , also shown in the maps in Figures 6 and7, this network does not reveal the patterns behind this configuration, which is why the spatial distances proposed in the methodology must be used. The technique studied provides a view of theft behavior and the relationships of each criminal event from the space-time variables, from much smaller temporal and spatial slices than those recorded in Figures 6, 7 and8. These slices are hourly and up to 100 meters. These smaller scales of analysis better explain the dynamics of theft in the city studied and are a powerful method of analysis for the criminogenic study of any space. The results obtained are recorded in Figure 9. They show three different ways in which the thefts are grouped according to their spatial dynamics: the expansive effect of theft , in which from one point they diffuse to two other points ; the compressive effect of theft , in which from two points they retract to one point; and the linear effect that indicates a displacement of theft . The three effects coexist and are determined as dominant when the proportion of any one is greater than the others. In terms of a diagrammatic explanation, one of the effects is dominant and creates a pattern when the cloud of dots shown in Figure 9 is concentrated in the upper part and not in the lower part. As for the expansive effect, this is not predominant at any of the time scales, nor at the proximal or micro scales. Some events have a greater intensity and proportion , especially in the pre-pandemic period, but their concentration is not homogeneous, which is why this is excluded as a conclusion. --- Discussion of the results The evidence collected allows us to affirm that the mobility restrictions, resulting from the COVID-19 pandemic, affected the theft dynamics in terms of the number of thefts. For two time windows , there was an average reduction in thefts of 38% . This result is logical, because the restriction limited the potential number of victims and even limited the mobility of offenders. In terms of spatial patterns, there is evidence of a displacement of thefts from the hotspots. This displacement ended up connecting two mixed zones to the west of the city and to the south of the municipality of Dosquebradas . It also coincides with the "natural" flow that occurs between the centralities of the two conurbations. In other words, the dynamics of thefts are proof of the displacement of the individuals who commit the crime. In this regard, it is important to note that the environmental munificence theory of crime helps to understand the creation of this new connecting axis of crime. According to this theory, the dynamics of crime are influenced by the criminal subjects' reading of the environment, allowing them to adapt to and benefit from the conditions offered by the location. Notably, the two corridors offer alternatives to criminals, such as national urban roads, where there are few windows and the vehicular flow is dense; facilities with significant physical deterioration; persistent street dwellers; consumption of drugs such as heroin; and limited escape areas. These attributes increase the probability of assaults by criminals. Other attributes include the existence of spare parts stores and food and grocery stores, which guarantee a constant flow of pedestrians. With respect to the space-time theft patterns, two elements should be mentioned: first, the MA-Pereira does not have a defined space-time pattern , as does occur with the theft dynamics in Medellín territorially dominated by any criminal organization . This is why there is no "illegal command" of this activity by any actor. There has also been a recurrent phenomenon in the city, because professional gangs of robbers usually exercise their criminal action in Pereira on a seasonal basis and come from other cities, mainly Bogota . These gangs tend to operate seasonally given the city's fertile environment for crime: urban decay in some sectors of the city, victims less With respect to the second factor, in MA-Pereira, the restrictions imposed by the APO did not affect the space-time patterns of theft in the city, which, as indicated in the results, there is no prevalence of one form over the other two . This fact confirms the inexistence of an actor that controls or orders the dynamics of theft. The place is where social interactions take place and where the meanings of these interactions are defined. Once the meaning of a place is configured for a whole community , everything from the inhabitants' identity to the use they give to the place -leisure, work or transi-is defined, thus, conferring sentimental value as well as economic value. As for theft, the places with the highest economic value are not necessarily those selected for this criminal activity . The locations selected for theft are those where there are more passersby and where criminals confer a meaning to the place based on their criminal practice, i.e., using it to commit crimes. This valuation of the place by the criminal subject is based on the cost/benefit ratio, the history of success achieved in previous crimes, and environmental munificence . --- Conclusions In the MA-Pereira, APO mobility restrictions reduced the theft rate, but did not modify the theft dynamics in the city; this is reflected in the space-time patterns, which were the same before and during the APO. These recurrent dynamics can be explained by the environmental munificence theory of crime, which indicates that crimes are committed due to the criminals' reading of the environment surrounding the criminal act. Of the three theft patterns, 2-Pah, In-2-Star and Out-2-Star, none predominate in Pereira; rather, they coexist. The pandemic did not alter this dynamic, i.e., in consolidating or dismissing the existence of one of the patterns. This is striking, given that the absence of space-time patterns, such as those analyzed, demonstrates elements such as the lack of territorial controls for theft by criminals or organized crime. On the other hand, the consolidation of the three patterns provides evidence that criminal subjects dedicated to theft are capable of adapting to the conditions of a munificent environment for theft. This is demonstrated by the fact that they are capable of configuring the three space-time patterns, even in an atypical contingency such as the coronavirus pandemic. The study of these spatial-temporal patterns that shed light on criminal dynamics on a proximal and micro scale, and on temporal scales in one-hour ranges, provides important tools when creating strategies to combat these criminal activities, with the added bonus of anticipating the geographic displacement that these activities would entail. This type of knowledge is innovative as an input for local and regional public policies against any crime. --- This scenario is similar for the comprehensive effect and for the linear effect. There is no dominant connection in either, demostrating that there is no pattern at the different spatial scales; in other words, there is no one form that takes precedence over the other. In this respect, the pattern at these spatial and temporal scales is the absence of a delinquent pattern, evident in the clusters shown in Figure 8.

2019 2020 2021 ). An approach to the theory of environmental munificence for crime• Date

Over the years, a growing number of international studies of family businesses have been conducted. In one review, Wortman found 144 countryfocused family business studies; 84 focused on the United States, Canada, or the United Kingdom, and all were single-country studies. Based on this, Wortman concluded, Presently, there are essentially no comparative studies of family business across cultural boundaries, ethnic boundaries, and country borders. Are there really differences in the ways in which family businesses operate sub-nationally, nationally, or globally? . . . Under what [environmental/] organizational contexts do family businesses operate most successfully? . Since then, more studies focused on family businesses in various nations have emerged and with greater consideration of contextual factors. Centeno-Caffarena found 120 articles published between 1977 and 2006 that examined the role of the institutional context of nations on family businesses. One third of the studies involved the United States, but other popular nations studied included Spain , China , and the United Kingdom . The most frequently examined institutional factors included culture , values , gender , conflict , networks , and social capital . In light of the emerging evidence, Smith issued a call for "new empirical studies that control for context," cautioning that "the differences between family and nonfamily firms may be less than many earlier studies have indicated and that industry differences and cross-national differences" may be more important. yielded 16 two-nation studies and 20 multination studies, some covering seven or more nations . A majority of the two-nation studies involved the United States or other Anglo nations. Most of the two-nation studies focused on identifying universal or common features within and between regions and/or examining how the local family business models or characteristics differ from the Anglo-based ones . For instance, Bewayo examined the applicability of the U.S.-or Anglo-based theories of family business to sub-Saharan Africa. The systems theory assumes a highperforming family business is good for the family in the long run. However, when families are pressed with more urgent subsistence in sub-Saharan Africa, this value is typically absent. Here, even a high-performing family firm may not be good-or desirable-for the family in the long run. A majority of the multination studies focused on the institutional antecedents of the family form of business and their performance effects . Most of these studies underlined the importance of institutional variables in supporting greater family control of businesses. It appears that the institutional inefficiencies are associated with greater family control of businesses but lower performance of family businesses as compared to nonfamily businesses, whereas institutional efficiencies are associated with lower family control of businesses but greater performance of family businesses as compared to nonfamily businesses. In other words, institutional efficiency moderates the relationship between family control of business and family business performance. There is still, however, a scarcity of multination comparisons on multiple dimensions of family business characteristics. Comparative multidimensional, multination studies are critical for enriching the family business disciplinary knowledge base through gaining a better understanding of possible causal relationships . Our work is a first step to fill this gap; it examines cultural variations in the family business dimensions, using GLOBE cultural clusters and the CASE project described below. --- Research Design: The CASE Project and Family Business Dimensions The CASE project, launched in 2005, seeks to complement a predominantly Anglo-centric worldview of family businesses by expanding it to other cultures, particularly in the emerging markets ; compare and contrast family businesses in distinct metaclusters ; and investigate the cross-cultural variations in family business dimensions . The CASE project uses nine dimensions of family business grouped into three categories, as shown in Table 1. The first category focuses on the family interface of the family business-that is, the extent of regulation of boundary with the family , the extent of family versus business as a source of reputation in the community , and the role of bonding versus bridging as a basis for relationships in the society at large . The second focuses on the business interface of the family businessthat is, the extent of the professionalism in the firm , the protection and scope of the family's power in managing the firm , and the competitiveness of the process of succession in leadership . The third addresses the joint interface of family and businessthat is, the role of gender in family business leadership , the role of time in family business longevity , and the role of space in family business advantage . The project was initiated when the five-member CASE research team issued a worldwide call for papers to nearly 100 family business centers and approximately 1,000 family business scholars. After receiving more than 200 manuscripts, the team reviewed each manuscript according to research method, data type, level of analysis, focus of study, and variables employed to obtain a representative sample. Ten articles were accepted for each of the ten GLOBE clusters. A tabulated list of the articles that were selected, including the nature of each study and key findings, appears in Gupta et al. . As part of the GLOBE program, Gupta, de Luque, and House suggest using content analysis of qualitative scholarly reports as a way to obtain unobtrusive scores on cross-cultural dimensions. Gupta et al. used thematic analysis , focused on identifying patterns or themes in the text, to codify culturally varying attributes. Applying this methodology to the present study, the construct of regulated boundary , for instance, was divided into three embedded concepts such as: the family business takes care of the family, as needed, the family lends a helping hand to the family business, as needed, and resources are used interchangeably for the family and/or business needs, as required. To ensure reliability of coding, one master coder rated all of the dimensions for all 10 clusters. Four other coders, who were trained by the master coder, also rated all of the dimensions for three or four clusters. Overall, each cluster was rated by the master coder and one additional coder . The process involved collecting supporting or negating evidence for each of the concepts from the set of 10 articles in each cluster. Following the GLOBE guidelines , the evidence was summarized into a 5-point scale rating: low , moderately low , moderate , moderately high , and high . Spearman's rank-order correlation coefficient between the ratings of the master coder and of the other coders for the nine clusters and nine dimensions was .78. Each of the two rater ratings was discussed, and a consensus rating was finalized, as shown in Table 2. Below we present the emergent themes, based on the thematic analysis of the nine dimensions of family business across the 10 cultural clusters. The relative roles and importance of the family's and business's reputations in terms of their relationships within the community; family resources are involved only if it makes business sense; the involvement of these resources is not guided by primarily family interests Bridging relationships The family business breaks out to access resources outside of the family's networks; it is not tied to only the family's networks for core resources Category II: The business interface Organizational professionalism The extent to which the family business employs professional managers and methods within the organization Regulated family power The extent to which the family business has a structure that protects it from the dynamics of family; family-as a collective or a divisive entity-does not create uncertainty for it Competitive succession The extent to which the succession process, including employment and leadership, is based on merit-based competence, as opposed to kinship; kinship alone does not entitle one to employment or the privilege of leading the family business Category III: The joint family and business interface Gender-centered leadership Women family members play visible and significant roles in the family business; they are not merely invisible or silent members of family in business Operational resiliency Family business has access to the reservoir of family resources to weather temporary crises or to overcome more enduring challenges; it is not without patient and loyal capital Contextual embeddedness Family business evolution is founded on the cospecialized and dedicated spatial resources, such as deep experiences and localized endowments --- Emergent Themes on Family Business Dimensions Category I: Dimensions of Family Interface Below are the emergent themes on the three dimensions of family interface, that is, regulation of business-family boundary , family versus business as a source of reputation , and bonding versus bridging as a basis of relationships . 1. Regulated boundary. Regulated boundary refers to the extent to which the criteria for the family business's access to family resources and the access itself are regulated. In some geographical contexts, the boundaries between the family and the business are strongly regulated; in others, they are permeable. As can be seen in Table 2, the regulation tends to be weakest in Confucian Asia and sub-Saharan Africa, both with a rating of 1. One illustration is that many family firms are operated in-or adjacent to-their residential dwelling. Every family member lends a hand in running the business, and within its confines, children and aging members are tended to. In resource-deficient sub-Saharan Africa, the same physical assets may be used for both household and business needs . The intermingling of family and business interests is common in the Middle East and Latin America. Both of these clusters received a rating of 2. Middle Eastern family businesses often provide support, including housing, living, and educational expenses for family members, even investing in new lines of business to accommodate them . In Latin America, Cruz and Howorth report, We were always taught to look after the family and the business, if any cousin was in trouble we had to help him or her, it was encouraged that we go in business with other family members and that we helped in their business as well, the same went for the people that work for us. Southern Asia, Nordic Europe, and Latin Europe were all rated at 3 on boundary regulation. Here an emergent theme was tempering the boundary between the family and business resources. An example of this theme is demonstrated in Southern Asia in how the family business supports the family's living standards and vice versa. The family business believes that each male family member "has the right to a certain reasonable standard of living and to be provided with the necessities to maintain such standard" . Similarly, in Nordic cultures, the family business is seen as the primary income source for the family and the family is expected to support it, especially when times are challenging . And in Latin Europe the family business supports the living standards of both the family and other stakeholders, such as employees and suppliers, as it subsequently relies extensively on them, as Musyck demonstrates in Belgium. The rating on boundary regulation for Eastern Europe and Germanic cultures was 4, as seen in Table 2. Here the emergent theme was the intent to achieve high boundary regulation, except during the family firm's formative stages or to ensure the family legacy. An example in Eastern Europe is that resources, such as the family's automobile, are deployed, often on a complimentary basis, during the firm's formative years. In Slovenia, "owner-managers are strongly convinced that family and business affairs should be kept separate, in particular in a period of difficulty, so that family problems do not harm the business and vice versa" . According to Peters and Buhailis , the desire to preserve the family's legacy is illustrated in the Germanic culture wherein the family firm's priorities may be more reflective of the lifestyle the family wants to follow rather than rational business principles. Finally, the Anglo cultures were rated as 5 on boundary regulation, based on recurring observations of boundaries that are highly regulated at all times. One illustration is furnished by Craig and Moores in which the Dennis family in Australia professionalized its business by laying out clear boundaries to regulate the relationship between the family members and the business. 2. Business reputation. In some regions of the world, the relationship between a family business and its community is determined by its business reputation-that is, how well it meets the business community's and legal system's codes and standards. In other regions, the concept of family identity and reputation is more important. The significance of business reputation is weakest in Confucian Asia and sub-Saharan Africa, both rated as 1 on this dimension . A Confucian Asian example of this theme occurs when the family firm assumes the debts of family members in distress . It does so to protect the family's reputationbecause the family business is viewed as a marker for the family's status and social capital . In the Middle East and Latin America, business reputation was assigned a rating of 2. Here the emergent theme was how business reputation is a vehicle to achieve family prestige, which is of utmost importance. As an example, in the Middle East, many leading family business groups have a history of rags to riches, such as the Al Fahim Company , which sought to dominate its diverse market niches. Similarly, in Latin America, examples showed how families view diversified family businesses as a way to enhance their social prestige among family members , employees , and the power network . In Southern Asia, Nordic Europe, and Latin Europe, business reputation was rated as 3. Here the emergent theme was how the reputation and viability of both the family and the business are sought after. As an example, in Southern Asia, the family business is as an undivided asset of families. Sohaff Shawls in Pakistan was the quality leader: When acrylic emerged in the late 1970s as a substitute for wool, the family resisted switching to the new fiber because they felt that this was inferior-one that was unworthy of the Sohaff name. In Latin Europe, a culture of integrity and a focus on people are the basis for the reputation of a family business . In Eastern Europe and Germanic cultures, the rating for business reputation was 4. The emergent theme was how business reputation is important, as the family's sustenance depends on it. In Eastern Europe, a family firm often seeks help from friends to augment family resources, but as the business becomes established it breaks away from those bonds. Family firms recognize that "the use of networking and contacts can also be a drawback, especially when one depends on these practices too much" . In the Germanic cultures, one example was how the family aspect is meant to cultivate trust with stakeholders and to manage conflicts more effectively . Finally, in Anglo cultures the rating on business reputation was 5 because family firms' goal to achieve a strong business reputation was observed as a recurring theme. In these cultures, a reputable business not only attracts and maintains high-quality external partners but also can serve to attract the family's successors into the business. In the United States, for instance, Tokarczyk, Hansen, Green, and Down find a family-like culture fosters an "engaging stakeholder environment," which is translated into a market orientation and is a source of long-term competitive advantage. 3. Bridging relationships. Bridging relationships refer to the extent to which the family business transcends the dependence on resources within the family and home community by breaking out to form new relationships. Bridging extends to society at large, versus bonding that occurs within kinship and friendship enclaves. As can be seen in Table 2, bridging is weakest in Confucian Asia and sub-Saharan Africa, where it is rated as 1. In Confucian Asia, one emergent theme was how the scope of market relationships is guided by guanxi, with a tendency to engage with people of a similar culture-for instance, from the same village . Nearly the same occurs in sub-Saharan Africa, where family businesses cater to their local ethnic communities. To gain access to these markets, trust-based on kinship and ethnic links-is crucial . In the Middle East and Latin America, bridging relationships were rated as 2. Here, although family bonds remain dominant and emerged as a recurring theme, low-key, informal, and instrumental bridging relationships also exist. They occur using Western-educated children to mediate relationships with the multinational firms and treating long-serving employees as part of the family to encourage loyalty . In the Middle East, thematic analysis shows expatriates mediating external alliances to enable serving global markets. In Latin America, analysis suggested that because outsiders are generally not trusted, key external contacts are co-opted as family relationships through the strategic marriages of daughters. In Southern Asia, Nordic Europe, and Latin Europe, bridging relationships were rated as 3 because thematic analysis identified family businesses seeking to develop strategic bridging relationships beyond their core bonds. An illustration of this theme in Southern Asia occurs where different ethnic communities tend to dominate in distinct parts of the value chain, allowing them to form bridges. In Indonesia, for instance, the merantau leave their homeland, emigrating to areas where they are an ethnic minority. Supported by family members that remain in the homeland and other merantau, they launch new businesses . In Nordic cultures, an example included how new business relationships are cultivated through spouses, the spouses of children , and nonfamily employees. Littunen found that these external personal networks were greater in family businesses than nonfamily firms during the critical first 3 years. In Eastern Europe and Germanic cultures, the rating for bridging relationships was 4. In these cultures, the emergent theme was of relational bonds, formed with a goal to cultivate bridging relationships. To illustrate, in transitional Eastern Europe, family and friends enable creative networking that allows family firms to arbitrage market inefficiencies . In Germanic cultures, family firms strive to form strong and lasting bonds with their stakeholders, including suppliers, employees, customers, and the community. To this end, many family firms join Verbundgruppe, which offer combined purchasing power and services, such as shared advertising . Finally, in Anglo cultures, bridging relationships were rated as 5, as shown in Table 2. An emergent theme here was that of using bridging relationships to continually evaluate the pragmatism of being invested into relational bonds. Thematic analysis indicated that the activities, markets, and lines of business selected by family businesses typically are not similar to those of other families in the community. Even if they are , the relationship tends to be more business centric than family centric, as illustrated among Australian firms' natural progression from family centricity to business centricity . --- Category II: Dimensions of Business Interface Below are the emergent themes on the three dimensions of business interface. 4. Organizational professionalism. Organizational professionalism refers to the holistic adoption of professional management and methods; organizational strategies and structures are designed in a way that upholds professional principles and objectives. In sub-Saharan Africa, the rating on organizational professionalism, as seen in Table 2, was 1. Here, the emergent theme was that professionalism is limited to very few organizations. Most family businesses rely on traditional organizational structures, and they lack the resources to pay for professional managers . Some degree of professionalism occurs in the older family businesses, common among immigrant groups and firms in which sufficient capital has been accumulated to hire professional managers, educate offspring who join the firm, or invest in diversification. In the Middle East and Confucian Asia, the rating for organizational professionalism was 2; thematic analysis revealed that professionalism is typically limited to Note: 1 = low on the dimension, 5 = high on the dimension. Ratings provide a summary of the core qualitative findings. lower level operational decisions. In the Middle East, family firm leaders make financial and strategic decisions and share little information with successors, let alone any professional managers. Similarly, in Confucian Asia, strategic decision making involves the inner circle of the family. Some firms, particularly in hightech domains, however, are being pressured to hire professional managers because of their growing size . The rating for organizational professionalism was 3 for Latin America and Eastern Europe; a repeated theme was that despite a spirit of professionalism for even strategic decisions, the actual involvement of professionals is still limited. As an example in Latin America, within the Gómez families in Mexico, decisions are made by the founder or entrepreneur, trust is built up extremely slowly, and technical ability tends to be underappreciated . In Eastern Europe, we find that family businesses are not very open, they wither more in favor of family exclusivity . However, with competition, leadership roles are assigned to those members who have superior professional expertise. Thus, families are making strides to bring about change . In the Nordic region, Southern Asia, and Latin Europe, organizational professionalism is rated as 4. In these regions, thematic analysis reveals that professionals are empowered in operational areas and are included in strategic decision making but are generally excluded from financial decisions. In the Nordic cultures, an illustrative example is that professionals advancing to leadership positions, especially when successors are not available, must demonstrate a commitment to the business's plan and goals. In Southern Asia, one theme was a low transparency of financial decision making, but a higher or stronger level of professionalism in newer firms, which are usually started by younger family members, daughters, and daughter-in-laws and who typically have more professional education. Here, professionalism is also attributed to the second generation's ability to trust the third generation's growth ambitions . In Latin Europe, a common theme was how a transition to professional management, particularly in financial matters, represents a major hurdle for family firms because their closely knit culture makes it difficult to loosen control . The exceptions include later generation firms and technology-intensive, globally competitive contexts. In Germanic and Anglo cultures, the rating on organizational professionalism was 5. Here an emergent theme was that professionalism is of a sufficiently high priority for all but the smallest firms. As an example, although smaller firms' decision making resides with family members, larger and faster growing Germanic firms strongly integrate employees into core management processes and may invest in training to enable this . In the Anglo region also, professionalism pervades the entire organization, in terms of people, procedures, strategies, systems, culture, technologies, and governance. In fact, Craig and Moores note that in the Anglo region, professionalization can be challenging, not only because of its comprehensiveness but also because owners must learn to let go. 5. Regulated family power. Regulated family power refers to the degree to which the family business has defined the scope and power of the family in the firm's management, a structure that provides protection from the dynamics of family. The regulation of family power limits the ability of the family to govern the business based on its self-interests, goals, and values. Although family businesses can establish legitimacy with customers, employees, and investors by regulating the family's exercise of power, the regulation of family power varies across cultures. In Confucian Asia and sub-Saharan Africa, regulated family power is rated as 1; there is minimal regulation of family power because the family firm's core purpose is to serve the interests and values of the family. In Confucian Asia, this theme was exemplified in ethnic Chinese business groups who have strong family control, despite financial holdings that may total billions of dollars and range over a wide variety of industries as well as countries . In sub-Saharan Africa, the examples abounded regarding the difficulties of regulating family power, given that the family and the family business share the space, resources, and kinship contacts. Too, centralized decision making nurtures a spirit of paternalism, and workers often call the founder "papa" . In the Middle East, Eastern Europe, and Latin America, the regulated family power rating was a 2. A common theme that emerged was that the family business serves the interests, goals, and values of the family but regulates the family members who will exercise more-or anypower. In Middle East, several family businesses are privately owned by one family . Because of the Islamic emphasis on patriarchy, all decision making defaults to the CEO or chairman . However, the laws of Sharia assign rights to all family members, including wives, sons, and daughters, so some norms of regulating power are required to support the education of successors, professional and expatriate managers, and partnerships with multinationals. In Eastern Europe, examples showed that those family members with stronger professional expertise and business contacts will have a differential voice in management and share in ownership. Finally, in Latin America, we found several examples showing that "it is the family . . . that concentrates the power to formulate and decide the strategic orientation" . Here, there may be no shared family decision making-the paterfamilias is consulted on all matters and makes all decisions. In Latin Europe and Southern Asia, regulated family power was rated as 3. In these regions, a dominant theme was how family power is emphasized, but regulated, to foster undivided continuation of the business. As a Latin European example, family businesses are expected to remain in the hands of the family, so they delay creating a board, have smaller boards, and avoid independent external directors. Italian male family business leaders also marginalize some members' activities, thereby lowering the likelihood that "outsiders" will advance in the firm . Similarly, in Southern Asia, there were several examples in which joint and undivided ownership of family firms makes any family member's exit highly contentious, resulting in acrimony. To maintain continuity and prevent breakups, Southern Asian family firms often offer investment support for new lines of business . In Nordic and Germanic cultures, regulated family power was rated at 4. Thematic analysis revealed regulation of family power as being guided by a principle that demands total commitment from members. There were several instances of various family members working in different parts of the business but with concentrated ownership and centralized leadership. These individuals tend to develop family business-specific learning through education and experience and are often well compensated. In Anglo cultures, regulated family power was rated as 5. The emergent theme was not only the regulation of family's power but also the transparency of this regulation. Several examples were found of ownership that is structured to enable easy exit by any family member in favor of other family members or another strategic investor. In terms of management, the family members tend to prepare themselves for the business's needs rather than the business creating positions for them . 6. Competitive succession. Competitive succession refers to the degree to which the successors must demonstrate their competence to earn employment and leadership in the family business; kinship alone does not guarantee the right to be employed or the privilege of leading the firm. Cultures vary in terms of how competitive the process is for selecting, nurturing, and advancing leaders. In Confucian Asia and sub-Saharan Africa, competitive succession is rated as 1. As one example, Confucian Asian successors are often groomed from a young age; nonfamily employees may become temporary successors, but they are expected to train and transfer leadership power to family heirs . In sub-Saharan Africa, there were several examples of successors who were uninterested in taking over, either because the business had limited resources and relied mainly on the physical labor and personal contacts of the family business owner or because appointing a successor was harmful to harmonious family relations. So most family businesses either shut down or are handed over to anyone who is interested in their continuation, perhaps because of no alternative employment option . In the Middle East and Eastern Europe, competitive succession is rated as 2. A dominant theme is that a family firm typically provides employment for family members, and family patriarchy is the dominating principle. In Eastern Europe, for example, many Lithuanian founders "would like to eventually turn their businesses over to their children" , so successors learn about the business through various support roles and voluntary services in their early years. In the Middle East, several examples emerged of parents beginning to groom children at a young age and often sending them to universities overseas to learn important business skills . Although predecessors retain the reins until their death , the pool of eligible successors in many instances is guided by Muslim laws, based on gender and birth order . Competitive succession was rated as 3 in Latin America, Southern Asia, and Nordic cultures. Here an emergent, common theme was that family members feel obligated to join the family business, and the family assists with their preparations. In Latin America, as an example, Howorth and Ali indicate that succession is a systematic process, involving a distinct series of events in which a family member is always chosen as the successor and work experience inside the family firm is viewed as the most useful preparation. In Southern Asia, several examples showed the male founder dividing ownership among sons equally, with their roles varying according to their educational backgrounds, skills and aptitudes, and personality characteristics . Similarly, in Nordic cultures, exemplar themes included successors preparing themselves through education, being socialized into the family business's social networks, working within the business, and participating in decision making. Succession is passed to the son or, if there is no son, to the son-in-law. In Germanic cultures, competitive succession was rated as 4, with themes identifying explicit efforts to prepare family members for eventual succession. Successors are often encouraged to take specialized education and internships in areas related to the family business and to work in other firms to learn new ideas that they can bring to the family firm. Though ownership may be transferred to all the siblings in an egalitarian manner , in family businesses led by males succession is usually ceded to the male son . Finally, in Anglo cultures, competitive succession was rated as 5. A common theme was one of family members making their own choice about whether to pursue education and gain experience relevant to the family business. Offspring are rarely obligated-or obliged-to join the family firm. Criteria for succession are specified, and successors must demonstrate competency to earn leadership positions. Predecessors transfer their knowledge and assign responsibilities in accordance with successors' competence and interest . --- Category III: Dimensions of Joint Family and Business Interface Below are the emergent themes on the third category of dimensions pertaining to the joint interface of family and business. 7. Gender-centered leadership. Gender-centered leadership refers to the degree to which women family members play important strategic roles in the family business; they are not merely silent and invisible members within the business. However, women's visible involvement in the family firm varies across cultures. In Confucian Asia and the Middle East, gender-centered leadership was rated at 1. The theme emerged that women are often not expected to be involved in the family business. In Confucian Asia, examples abounded of how succession occurs only to male children . If no competent or interested son is available, then even if she is not interested, a daughter is morally obligated to join the firm and help her parents. Similarly, in the Middle East, examples showed that female heirs are considered for employment in the family firm only in times of an emergency and/or in support roles . Other employees often attribute women's positions in relation to the boss and often bypass their authority as if they were not there at all . Wives tend to be active in the ladies' circles, organizing social events. A similar situation traditionally existed in Latin America, Southern Asia, and Latin Europe, but gendercentered change is occurring and at a significant pace, earning these regions a rating of 2 on gender-centered leadership. As an example, Lomnitz and Pérez-Lizaur note the Gómez sons in Mexico generally inherit one or more independent enterprises. Daughters do not normally inherit enterprises unless their husbands [or brothers] happen to be in charge of a particular business. A daughter's share of the inheritance is not necessarily smaller than that of her brother, but it normally consists of real estate, antiques, works of art, jewelry, and other investments. However, this is changing, and many wives have founded businesses jointly with their husbands. As another example from Southern Asia, in the Murugappa Group, a large company in South India, only the male members of the family are allowed to participate in the leadership, management, or shareholders' meetings, despite all wives and daughters having received a "good education" . Similarly, in Pakistan, women's interests are subjugated to those of the male elders, unless they have independent businesses, which are stereotypically feminine, such as schools, beauty shops, and boutiques . The role of women is primarily to assist with social and community outreach. Yet daughters are increasingly gaining rights to the family estate, particularly if there are no sons. In Latin Europe, laws mandate ownership rights for the daughters, yet they may be excluded from intergenerational succession to preserve the family's legacy, often despite greater education . Among Italian family firms, for instance, women primarily serve in operating and supporting roles and must prove their credentials as deserving leaders . In Nordic and sub-Saharan Africa, gender-centered leadership was rated as 3. A common theme was that women are able to secure leadership positions but are held to higher standards and/or must make do with more limited resources. In Nordic cultures characterized by relatively high gender equality in the formal arenas , examples of gender inequalities are found both within and outside . As such, daughters do not become CEOs; that position typically goes to their husbands, if they have no brother or brothers. Increasingly, however, daughters are being offered the CEO and line positions, but their performance is measured against higher standards. In sub-Saharan Africa, daughters have independent and equal rights to the capital but have limited capacity to use it because of more limited-or no-access to education. As an example, women's operations are smaller, are "less serious," are more likely to be home based than men's, and are more likely to be started on a proverbial shoestring because of their child care and domestic obligations . In Germanic and Anglo cultures, gender-centered leadership was rated at 4. Here the emergent theme was of women being able to assume leadership positions, and their involvement was seen as beneficial, although their roles remained structured in such a way as to preclude meaningful participation. For example, in Germanic cultures, it is now common for daughters to succeed, especially where both the father and mother are actively involved in the family business. Still, although almost 63% of all spouses work in the family business, only 8% of all CEOs of medium-sized family businesses are female . The wives' participation is seen more as enhancing the family's social status and serving as a confidant and advisor to their husbands. In Anglo cultures, women are beginning to play active leadership roles, if they are competent and interested in participating. Daughters are granted the same rights as are sons to the family estate. Yet their roles remain structured in a masculine manner, making it unviable for many daughters to be actively engaged in senior positions because of a higher level of conflict between work and family responsibilities . In Eastern Europe, gender-centered leadership was rated as 5. The emergent theme was one of women actively participating in leadership roles but facing significant competition from male members trying to take over. Daughters, as well as sons, often help on an unpaid basis and may also take over the business. Wives may assume a superior leadership role if they are more educated than their husbands, or they may take a coleadership role if they are as educated as their husbands. For instance, in Siberia, "gender structure of family companies appears to be distributed fairly" . 8. Operational resiliency. Operational resiliency refers to the degree to which the family business has access to the reservoir of family and community resources to weather temporary crises or to overcome more enduring challenges. It is reflective of the flexibility, agility, stability, sustainability, and longevity of the family business. In most cultures, family businesses enjoy operational resilience-patient and loyal capital to draw on in times of emergency or need-however, the depth and nature of this resiliency differ. Its depth is low in the transitional cultures of Africa, the Middle East, and Eastern Europe, where it is rated as 3. In sub-Saharan Africa, the life of most family businesses is short and their size is small, although family businesses are able to flexibly acquire resources through a system of exchanging favors with selected people, based on trust. In the Middle East, several instances showed how a major goal for a family business is to have adequate resources to provide for one's family, so they do not diversify to minimize risk . When they do, it is generally to enhance the firm's or the family's reputation , particularly under conditions of limited competition, when children have been educated abroad, or with substantial support. In Eastern Europe, several examples showed family businesses as having become adept at exploiting arbitrage opportunities in inefficient regional markets, but hostile economic environments can threaten their resilience. A study in Cyprus shows challenges to change: "The strong social ties that previously sustained, and even contributed to the growth of such firms, become stifling factors that slow down the company in environments where the rate of external change has increased" . The depth of operational resilience was higher in the Western cultures, being rated at 4. In the Anglo region, as an example, competitive forces and professional managers allow frequent changes in the strategic direction. Family firms are pervasive in less economically developed and in culturally cohesive communities and are adapted to compete in environments of poverty, crime, and recession . In the Germanic region, illustrations were found wherein family firms often pursue related diversification, with various family members developing competencies in different domains to enable resiliency. In the Nordic region, although family firms tend to operate in traditional sectors, their willingness to innovate and make changes to remain competitive is aided by family ownership that promotes motivation and long-term plans . In Latin Europe, thematic analysis showed how family firms craft a niche of specialization and a culture of cooperation horizontally and vertically with other family firms, allowing them to be the vehicles for regional transformation. The operational resilience was strongest among the Asian and Latin American family businesses, rated as 5. In Confucian Asia, examples abounded of core business groups that obtain varying degrees of ownership in dozens of small-to medium-sized businesses, resulting in a web of holdings, reinforced by placing family members in key positions . Trusted employees are co-opted to execute major changes if family members are not available. Carney and Gedajlovic observe that this allows response to globalization and new technologies. The theme of operational resilience was also evident in Southern Asia. For instance, Connelly's Indonesian merantau firms show resilience when their members leave their homeland to seek business opportunities elsewhere and then reinvest in other merantau firms. In Latin America, holding structures emerged as a theme that allow differentially involving outsiders in various businesses as well as using strategic marriage alliances to bring about renewal. Here, Lomnitz and Pérez-Lizaur find that resilience occurs through social capital or networks, an increasing level of professionalism, and an increasing emphasis on education for both family members and nonfamily managers. 9. Contextual embeddedness. Contextual embeddedness refers to the extent to which family business evolution is founded on the cospecialized and dedicated spatial resources, such as deep experiences and localized endowments. In all cultures, one finds evidence where "the family-owners feel responsibility for the community, and the community, that is, its local authorities and inhabitants, in return back 'their' family business" . Therefore, as seen in Table 2, all the regions were rated at 5 on contextual embeddedness. The logic, nature, and manifestation of the contextual embeddedness, however, differ across culturessuggesting qualitative variations. In Confucian Asia, cultural affinity, social marginality, and Western hubris form the basis for family businesses to establish minority joint ventures, licensing agreements, and technology-sharing agreements . In Southern Asia, the Murugappa family follows the Nagarathar tradition of its community and believes in respect for elders in all matters , prudent spending, balance in living , and stewardship and judicious use of resources to support others in the community . In African cultures, there is a great respect for ancestors and elders, who are seen as symbols of knowledge, experience, and wisdom , so family businesses tend to rely on them for their superior knowledge about local resources and networks. In the Middle East, Islamic teachings mandate the patriarch has a duty to provide for his family, so he may avoid new business ventures or expansion if he is already adequately providing for his family . The Koran also requires that one's commitment is to a greater group . As a result, many generously donate to worthy causes within their communities . In the Anglo context, contextual embeddedness is a key influence on the organization's goals, attitudes, and practices . In a study by Ogbonna and Harris , a British business owner espoused values of equality, simplicity, harmony, paternalism , and community, which were reflected in the firm's philosophies and policies. In the Germanic region, the stakeholder context is guided by a distinctive codetermination model with a joint historical influence of family and business partners, the community, and employees. A sense of history justifies the firm as a family affair across generations . In the Nordic region, the external influence of community and ecological stakeholders is even stronger among the family firms, which is reflected in their environmental and social consciousness . Sometimes, the thrust is on responding to the business opportunities while maintaining family bonds. In Eastern Europe, a study in Lithuania finds a hostile environment of "declining GDP, declining purchasing power, high inflation, lack of skilled workers due to poor education system, lack of infrastructure, and corruption" . In Latin Europe, family businesses develop integrated local networks, involving the employees, suppliers, customers, and communities, with a sense of regional pride. Howorth and Ali note the impact of culture on the value placed on education, which, in turn, affects the preparation of potential successors. In Latin America, "privileged" status in society or elite groups, such as the military and the Church, is critical . --- Conclusions The emergent themes reported in this study indicate significant quantitative, as well as qualitative, variations in the family business dimensions across different contexts. These themes enrich our understanding of the diversity of family businesses across the world. The study is, however, only one step in the study of this diversity, as the actual diversity is likely to be much higher. First, regional systems do not have a single, homogeneous culture. The GLOBE results suggest that the regional systems account for more than 50% of the cross-cultural variation in the organizational practices and values. Yet regions are also differentiated into several subculture systems, which intersect and diverge around several factors such as subgeographies, institutions of governance and markets, regional industrial and economic imbalances, family systems, ethnicity, religion, gender, generation, and class. For instance, in the Middle East, women are usually not considered for employment in the family firm. However, in the United Arab Emirates, the government has been encouraging families to offer the best education to their daughters and to include them as family business owners and successors as a way to preserve ethnic identity and national interests. The native Emirati population is a minority 10% in the nation, and the immigrant expatriates fill most leadership positions. Women are taking up the challenge enthusiastically, which will likely lead to profound changes in the dimensions we investigated. Furthermore, the cultural attributes of the regional systems and the factors that are correlated with these cultural attributes-such as economic development, education, industry and technological configuration, and governance systems-are not immutable or frozen in time. Moreover, regional systems are not closed but are open and fluid; they interact with the other regional systems worldwide. Thus, cross-regional encounters produce an exchange of ideas and perspectives, values and practices, and techniques and technologies as well as of individuals, organizations, markets, and institutions. For instance, the concept of family itself is being challenged in the Confucian culture, as the foreign investors and partners are brought within the purview of those with whom guanxi ought to be cultivated. Finally, the characteristics of the family and of the business are important. Differences in size, education, and global awareness of the families and differences in the size, life cycle, technology, and industry of the family businesses will have an influence on the findings reported here. For instance, in Latin America, as the Mexican Gómez families have expanded into globally competitive businesses and have sent their children to be educated overseas, they have found nepotism to be ineffective in attracting the relevant resources and have become increasingly receptive to organizational professionalism. Beside the above boundary conditions, another limitation is that the articles used for the thematic analysis are secondary data, which may not adequately portray information that is truly representative of family businesses worldwide. This study may be capturing dominant themes in the types of family businesses that have been researched, but it is also possible that additional themes-or even counterthemes-may be present, which could emerge through further research in each cultural context. Despite its limitations, the study underscores the importance of contextual and cultural differences in the characteristics of family businesses. The dimensions discussed in this article will be useful in aiding future comparative and multination research on family businesses. Further research might examine how these dimensions are interrelated with various contextual variables, such as economic development, education, industry and technological configuration, governance systems, societal culture, and religious and legal systems. It would also be useful to investigate how these dimensions vary across families or family businesses along certain characteristics, such as size. The body of knowledge about family businesses in various regions of the world is still in its formative stage. Consequently, we hope that a contribution of this work is to document the known themes about family business dimensions in cultural clusters worldwide so that it may serve as a guide for further research that either further refines evidence on these themes or offers evidence on other themes. In doing so, this should lead to a more culturally sensitive understanding and appreciation of family businesses, and both their similarities and differences, around the globe. Too, given increasing mobility and transmigratory patterns, it seems that a richer understanding of family businesses would be helpful and useful to researchers, practitioners, and consultants alike. In conclusion, this research suggests that Anglobased definitions of family business and the largely Anglo-based underpinnings may be insufficient for truly understanding family businesses in a global sense . The differences that we find across cultures along the nine family business dimensions suggest that current definitions may not be transferrable globally. Our results challenge family business researchers to think more "globally" if they want their efforts to be relevant in today's world. --- Declaration of Conflicting Interests The author declared no potential conflicts of interests with respect to the authorship and/or publication of this article. --- Financial Disclosure/Funding The author received no financial support for the research and/or authorship of this article.

This article shows cross-cultural variations in family businesses using nine cross-cultural dimensions of family business from the CASE project. A content analysis of the emergent themes from a set of contextual articles on family businesses in 10 regional clusters worldwide, as defined by the GLOBE program, is conducted. This thematic analysis shows qualitative as well as quantitative variations in the family businesses of different cultural regions. Further research is required to understand the rich diversity of family businesses within each cluster and to refine scholars' knowledge about how the dimensions of family business are manifested in different clusters.comparative study, thematic analysis, family business dimensions, the CASE project, the GLOBE programWe searched the leading electronic databases (e.g., ABI/ INFORM, EBSCO, and Business Source Premier) to identify multination studies that had been conducted since the mid-1990s and their contexts. Our search

Background The potential contribution of health providers' racial/ ethnic bias to ethnic health inequities is an area receiving increasing research attention [1][2][3]. Bias can be defined as "... generally negative feelings and evaluations of individuals because of their group membership , overgeneralized beliefs about the characteristics of group members , and inequitable treatment " [3], p201. Within this, explicit bias is considered "conscious and intentional" [3], p201, and implicit bias "unconscious and automatically activated" [3], p201. Racial/ethnic bias exists within a broader system of racism that structures opportunity, resources and power by race/ethnicity, with multifarious expressions that impact on health in many ways [4], and is one possible manifestation of this broader system [2]. Studies examining health professional racial/ethnic bias to date are largely US based and focused on pro-White/ anti-Black race bias [5][6][7]. They consistently demonstrate pro-white racial/ethnic bias among health professionals, although relationships to healthcare vary [5][6][7]. Implicit racial bias has been shown to impact on the quality of healthcare encounters [8], and on clinical decision-making [9,10], although not consistently [11][12][13][14][15]. Within this field, most studies have been undertaken among physicians, with very few among medical students [12,16,17]. In a study of 211 students entering a US medical school, the majority of participants demonstrated an implicit preference for 'white' people [12]. Explicit preference for 'white' people was also present although not as pronounced as implicit preference. No consistent differences were found in vignette assessment by patient race or in the relationship between racial/ethnic bias and clinical assessment in this study [12]. In another US study of students entering medicine, nursing and pharmacy, medical students demonstrated an implicit preference for 'Whites' and a preference for lighter skin tone [16]. In a study of third year medical students, Gonzales et al. [17] also demonstrated that medical students were more likely to have an implicit "preference for people like themselves" in a sample where the majority of students were 'White'. In 2013, the New Zealand population was 4.4 million with 14% Māori and 70% European [18]. Major inequities exist for most health measures, including healthcare access and quality, between Māori and non-Māori [19,20]. Māori report higher experience of racial discrimination by health professionals compared to Europeans [21], with qualitative evidence of negative beliefs and stereotypes about Māori among health professionals [22,23]. The current project explores ethnic bias and clinical decision-making amongst medical students, as part of a broader project on how medical education can address indigenous health inequities. As with all health professionals, medical students in NZ are likely to be exposed to a range of discourses and stereotypes about Māori, both within medical education and in broader society. Research is needed to expand the body of evidence of racial/ethnic bias among medical students in general. Understanding medical student bias may provide for improved learning environments for both students and teachers and reduce future impacts of racial/ethnic bias on ethnic health inequities. It is important that this occurs within and across country contexts, in order to capture the similarities and differences in how racial/ethnic bias may operate for different populations and in different health systems. This research will also provide relevant information to support medical education in particular locations. In addition, the examination of bias and the implications for Māori health and ethnic inequities in New Zealand provides information from an indigenous health perspective that is internationally relevant and for which studies are also limited [14,24]. This study sought to measure ethnic bias towards Māori compared with NZ European among final year medical students, assess differences in clinical decision-making responses to chronic disease vignettes for Māori versus NZ European patients, and examine associations of implicit and explicit ethnic bias with clinical decision-making. Given the evidence of ethnic healthcare inequities between Māori and non-Māori, and negative beliefs about Māori held by healthcare professionals , we hypothesized that medical students would exhibit ethnic bias favoring NZ European, differentially respond to management decisions by patient ethnicity, and that ethnic bias would be associated with differential management by patient ethnicity. --- Methods --- Study design A web-based cross-sectional study was undertaken with final year NZ medical students in two consecutive academic years. Study development, pretesting, piloting and final questionnaire are detailed elsewhere [25]. The study was approved by the University of Auckland Human Participants Ethics Committee and ratified by the University of Otago Human Ethics Committee. --- Participants and data collection Email invitations and a password to enter the study were sent to all final year medical students via student administrators at the Universities of Otago and Auckland in November 2014 and January 2015 . For each group, the study website was open for 12 days during which two to three reminder emails were sent. On entering the study website, after reading an information sheet, participants were required to consent in order to proceed. Participation was anonymous and voluntary. Participants were offered a $20 electronic gift voucher and the chance to enter a draw for a $500 gift voucher. In order to minimize bias from knowledge of the study's purpose, initial information did not specify a focus on ethnic bias, although additional information was provided at the end of the questionnaire. To minimize social desirability bias [26] study content was ordered as: key demographics; vignettes; two implicit bias measures; social desirability scale; explicit bias measures; and, additional demographic questions. As explicit bias may be more prone to participants providing socially acceptable responses [7], we placed this module last so as not to influence the responses to the other modules. 302 students entered the study. 287 participants answered at least one vignette module, while 280 participated in both. Participant characteristics were proportionally similar to the invited student group by age, gender and ethnicity . --- Key variables Chronic disease vignettes Two existing clinical vignettes focused on cardiovascular disease and possible depression [9,27] were adapted with permission for the NZ context, using a process of clinical review and revision [25]. Participants were asked about diagnosis and management for the vignette patients [9,25,28]. To examine differential responses by patient ethnicity, the vignettes described patient ethnicity as either Māori or NZ European, with common English or corresponding Māori language surnames used as additional ethnicity 'markers'. The particular patient ethnicity seen for the two vignettes, and the order of these vignettes for a given participant, was randomized so as to balance these factors across all participants . The cardiovascular disease vignette described a 50-year-old man presenting to a regional hospital emergency department with chest pain and ECG changes suggestive of myocardial infarction . Participants were asked to rate the likelihood that the pain was due to coronary artery disease , and their recommendation in relation to thrombolysis [9]. Thrombolysis responses were reverse scored for analysis. Following additional information and instructions to give thrombolysis for a likely MI, participants were asked about their subsequent management if the patient refused thrombolysis [9]. The depression vignette described a 44-year-old man presenting to his general practitioner with generalized symptoms including muscle aches, insomnia, headache, irritability and reduced concentration, and a past history of depression. Participants were asked to rate the likelihood that the patient's symptoms were due to depression [9], the severity of the patient's symptoms and to rank from 1 to 5 their preferred initial management approach from a list of options: a) encourage self-help strategies; b) refer to social support and counseling services; c) recommend anti-depressant treatment; d) refer to primary care brief intervention service; and, e) commence antidepressant and refer to specialist mental health services) [25]. Participants also rated the likelihood that the patient would benefit from the selected initial management approach [28]. --- Implicit bias measures The implicit association test is well validated [29] and the most commonly used implicit bias measure in studies examining racial/ethnic bias among health professionals [5,6]. The IAT is a computer based response latency measure where participants have to rapidly sort stimuli into target categories and attitude or stereotype categories [29]. The IAT measures the relative strength of association between the contrasted groups with respect to how quickly different pairs of stimuli are sorted [30]. Two IATs were included, an 'ethnicity preference IAT' and an 'ethnicity and compliant patient IAT' adapted from the corresponding race IAT [31], and race and compliant patient IAT [26]. Adaptation included using NZ specific ethnic group categories with corresponding prototypical Māori and NZ European photographs [25]. The 'ethnicity preference IAT' required participants to sort prototypical photographs of Māori and NZ European people with word stimuli representing general concepts of 'good' and 'bad'. The 'ethnicity and compliant patient IAT' required participants to sort the same prototypical photographs representing ethnicity with word stimuli representative of 'compliant' and 'reluctant' patients. The full set of word stimuli have been previously published [25]. IATs were built and hosted securely by Project Impli-cit® using a 7-block structure [32]. Participants linked directly to the IATs from the online study. Project Implicit provided raw latency data and calculated IAT D-scores using standard guidelines [32]. Participants were excluded following standard criteria [32,33]. A score of 0 indicated no implicit preference by ethnicity or no implicit compliance stereotype by patient ethnicity. Negative scores were pro-Māori for that measure, and positive scores were pro-NZ European . --- Explicit bias measures Ethnic preference for Māori compared to NZ European was examined on a 7-point scale [9,32]. Responses were reverse scored so that higher values indicated higher preference for NZ European. Warmth towards Māori and NZ European was assessed on separate 7-point scales from 1 = Feel LEAST WARM Toward This Group to 7 = Feel MOST WARM Toward This Group . Warmth difference scores were calculated for each participant , with positive scores indicating greater reported warmth towards NZ European Frequencies for 'Not reported' represent individuals who did not reach the final section of the survey tool where these questions were asked, plus one individual who did not complete all questions in the final section compared to Māori, and negative scores indicating greater warmth towards Māori. --- Other covariates We examined sociodemographic variables to check the vignette randomization process. These variables included age , gender , ethnicity [35], nativity , and self-reported socioeconomic position growing up [9]. Participants also completed the RAND 5-item Social Desirability response set [36] scored from 0 to 5 . --- Data analysis All data were analyzed using R 3.1 . As some participants did not complete the entire study/testing procedure, analyses are restricted to those individuals participating in that stage of the study protocol. Responses were deleted for both the implicit and explicit bias measures if the respondent used a touch-based device . The results section explicitly reports the number of participants contributing to each analysis. Descriptive statistics are presented by randomized patient ethnicity vignette group to allow consideration for potential residual differences between groups following randomization. Sociodemographic variables are summarized with frequencies and percentages and medians and interquartile ranges . Implicit and explicit bias measures are summarized with means and 95% confidence intervals . Responses to vignette questions are summarized with means and 95% CI by randomized patient ethnicity for that vignette. For each vignette question, the difference in means by patient ethnicity is also presented . We examined the association between implicit/explicit bias measures and each of the analyzed vignette questions using linear regression. As each participant only completed a vignette for one randomly assigned ethnicity, the difference in the slopes of these lines was compared using interaction terms in the linear regression models . These results are reported for each vignette measure as the estimate of slope in each of the two randomly assigned patient ethnicities alongside the difference in slopes between participants assigned the NZ European ethnicity vignette and participants assigned the Māori ethnicity vignette . To control for inflated Type I error rates from multiple hypothesis tests, we also considered results against a more stringent alpha value in analyses of clinical decision-making by patient ethnicity and its associations with measures of ethnic bias. We used a Bonferroni correction to allow an overall family-wise error rate within each vignette section of 0.05, which gave a more conservative alpha of 0.0125 for each comparison , correcting for around 4 tests within each section. For example, for the mean differences between NZ European and Māori patients on vignette items, there were 3 vignette items for the CVD vignette and 4 for the depression vignette. For the regression analyses, there were analyses for 4 different bias measures within each vignette question. --- Results Table 1 summarises participant characteristics overall and by randomized patient ethnicity for each vignette. Generally, characteristics of study participants were evenly distributed across vignette patient ethnicity groups. In the CVD vignette, Asian participants were more likely to receive a NZ European patient, and European participants were more likely to receive a Māori patient. There were also minor differences in distribution of Social Desirability scores by vignette patient ethnicity, although these were at the lower social desirability end of the scale. Ethnic bias was apparent for implicit and explicit measures . A mean ethnic preference IAT D-score of 0.39 indicated an on average 'moderate' implicit preference for NZ Europeans compared to Māori. On average, participants also showed a 'slight' implicit association between the concept of a 'compliant patient' and NZ European patients compared with Māori patients . On explicit measures we observed higher warmth toward NZ European compared to Māori and a mean ethnic preference for NZ Europeans compared to Māori . No systematic differences in ethnic bias were seen by randomly assigned patient ethnicity for each vignette. There were no significant differences by patient ethnicity on diagnosis and management questions in the CVD vignette . For the depression vignette, the likelihood of depression, severity of symptoms, and the estimated benefit of treatment did not significantly differ by patient ethnicity. For the recommended initial management approach item , rankings were similar for the NZ European and Māori patient vignettes for the top ranked and bottom ranked items . For the NZ European patient vignette, the three middle options were ranked in order of preference from 2) recommend antidepressant; 3) refer to primary care brief intervention; and 4) refer to social support and counselling. These three responses received similar mean rankings for those who viewed the Māori patient vignette . However, only referral to social support and counselling services was ranked significantly higher for the Māori compared to NZ European patient. Recommending an antidepressant was ranked higher for the NZ European than the Māori patient, although this was not significant under the more stringent alpha level of p < 0.0125. Table 4 shows the associations between participants' bias measures and vignette responses by patient ethnicity, alongside differences in associations by patient ethnicity. For CVD, no significant differences were found between slopes by patient ethnicity at the alpha of 0.0125. In the depression vignette, explicit preference for NZ Europeans was associated with students reporting an increased likelihood that NZ European patients would benefit from the selected initial management approach ; while for Māori patients the slope was close to zero , and the differences in slopes by patient ethnicity was significant . No other vignette items showed a significantly different relationship with ethnic bias according to patient ethnicity. --- Discussion This is one of only two known studies to examine racial/ ethnic bias and associations with cliical decision-making among medical students [12] and to our knowledge, is the first among medical students or any health professional group in New Zealand. The findings were mixed with regards to our hypotheses. Medical students demonstrated both implicit and explicit bias favouring NZ Europeans compared to Māori. However, we only found very limited evidence of differential decision-making by patient ethnicity, including differential associations between ethnic bias and clinical decision-making, with only two statistically significant findings among multiple tests . The mean pro-European implicit ethnic bias demonstrated in this study was similar to mean pro-white bias among US medical students using the Black-White race preference IAT [12,16]. Implicit bias scores that associated compliance more closely with NZ European than Māori patients were similar to findings among US physicians [8,10,26]. The examination of ethnic bias in our study among a sample of final year medical students and for Māori compared to NZ European ethnic groups addresses identified research gaps in the international literature in terms of knowledge of health professional ethnic bias towards other minoritized ethnic groups and the use of a more nationally-representative sampling frame [7]. Encouragingly, we did not find evidence of ethnic bias being linked to differential clinical decision-making by patient ethnicity. The study of US physicians from which the CVD vignette here was adapted, found that increasing implicit preference for 'Whites' compared to 'Blacks' was associated with significantly increased likelihood of recommending thrombolysis for hypothetical 'White' patients, and a reduced tendency to recommend thrombolysis for hypothetical 'Black' patients [9]. While our study found similar directions in the relationship between implicit ethnic bias and clinical decision-making for NZ European compared to Māori patients, these were not significantly different. There is evidence of differential prescribing of antidepressants in New Zealand, with lower rates for Māori [37]. While this pattern was seen in the depression vignette, with lower ranking of the prescription of an anti-depressant for Māori compared to NZ European, this did not reach statistical significance. The only significant finding for the differential relationship between ethnic bias and patient management in the depression vignette was the association of explicit NZ European ethnic preference with increased perceived likelihood to benefit from the selected initial management approach for the NZ European patient but not for the Māori patient. Both CVD and depression have known ethnic inequities in healthcare in NZ [37,38]. However, despite the presence of ethnic bias, only one finding showed significant differential relationships between ethnic bias and clinical decision-making by patient ethnicity. This apparent lack of a relationship between racial/ethnic bias and clinical decision-making is seen in previous studies using similar methods [5,39]. Amongst first year medical Encourage self-help strategies f 1. -0.01 (-0.23, 0. Refer to social support and counselling services 3. students in the US [12], pro-white implicit and explicit bias was demonstrated, but was not associated with differential responses to vignettes by patient race. A recent systematic review found that associations with race/ethnic bias have been more commonly reported in studies examining patient-provider interactions than in studies examining healthcare outcomes such as treatment decisions , patient adherence and patient health outcomes [5]. For example, in a study of US primary care physicians, implicit race bias and implicit race and compliance stereotyping were associated with measures of poorer communication such as verbal dominance, and poorer patient perceptions of clinicians [8]. Implicit bias can be expressed in interpersonal interactions through subtle behaviours such as friendliness, body language, expressions and quality of speech that can impact on the quality of the encounter [29,39]. These subtle expressions are less likely to be detected using vignette measures but may have subsequent impacts on patient care and inequities through pathways such as satisfaction and trust in healthcare, and adherence to recommended care [39,40]. Other study limitations should also be considered. Participant responses to hypothetical vignette scenarios may not correspond to behaviour in actual clinical settings [41]. In particular, individuals' implicit biases are more likely to be activated in situations with higher pressure and cognitive load that may be more common in real clinical situations [29,39,42]. It is possible that the use of words to describe ethnicity in clinical vignettes may elicit different responses than the use of visual images such as photographs. However, comparisons of implicit bias measures in New Zealand when using images or words to represent ethnicity have shown similar levels of bias in responses [43]. Although this study was designed to minimise the impact of social desirability, it is possible participants were aware of its purpose. Green et al. [9] found that participant awareness of the study purpose increased the likelihood of recommending thrombolysis to 'Black' patients. We are unable to examine the potential impact of this in our study although if it operates in a similar direction, our estimates are likely to be conservative. Ethnic bias was the focus of this study, and bias based on other attributes such as gender were standardised but not examined in the vignettes. Finally, the response rate and the absolute study numbers were lower than expected, which may impact on generalisability and study power. The distribution of participants by age, gender and ethnicity was similar to final year medical student demographic profiles, which is reassuring for the generalisability of initial questions such as vignette responses by patient ethnicity. Dropout of participants as they progressed through the online study may bias analyses using data from later questions although in analyses of vignette responses by patient ethnicity in a restricted sample of those who completed the questionnaire, patterning of results were similar. --- Conclusions To our knowledge, this is the first study of its kind among any health professional group in New Zealand and one of only a few among medical students internationally. The findings extend the evidence on health professional racial/ethnic bias beyond the current dominance of US-based studies, providing information on bias against other ethnic groups, including another indigenous population. While on average final year medical students expressed ethnic bias favoring NZ European patients compared to Māori, evidence of links to clinical decision-making were not found. Further research is required into the ways ethnic bias may be expressed in healthcare encounters, and ethnic bias among other groups including different student year groups, faculty, and physicians. Our findings demonstrate the need to address ethnic bias in medical student education in New Zealand, particularly in relation to indigenous health. This has implications for medical education and broader healthcare environments. Ethnic bias training that aims to understand, identify, mitigate and reduce ethnic bias should be included in formal medical school curricula. This is supported by evidence that inclusion of ethnic bias in formal curricula by trained instructors and improving student confidence in providing care for minority patients are associated with reduced implicit racial/ethnic bias [44]. Additional efforts are also needed to address aspects of the hidden curriculum and clinical environments that may increase ethnic bias [44] and to introduce health system factors that may mitigate expression of ethnic bias. Finally, the broader context of societal racism within which individual ethnic bias develops requires addressing [3,39]. --- Availability of data and materials Data will not be shared. This is a requirement of the ethics approval for this study. --- Additional file Additional file 1: Table S1 --- --- --- Competing interests The authors declare that they have no competing interests. ---

Background: Health professional racial/ethnic bias may impact on clinical decision-making and contribute to subsequent ethnic health inequities. However, limited research has been undertaken among medical students. This paper presents findings from the Bias and Decision-Making in Medicine (BDMM) study, which sought to examine ethnic bias (Māori (indigenous peoples) compared with New Zealand European) among medical students and associations with clinical decision-making. Methods: All final year New Zealand (NZ) medical students in 2014 and 2015 (n = 888) were invited to participate in a cross-sectional online study. Key components included: two chronic disease vignettes (cardiovascular disease (CVD) and depression) with randomized patient ethnicity (Māori or NZ European) and questions on patient management; implicit bias measures (an ethnicity preference Implicit Association Test (IAT) and an ethnicity and compliant patient IAT); and, explicit ethnic bias questions. Associations between ethnic bias and clinical decision-making responses to vignettes were tested using linear regression. Results: Three hundred and two students participated (34% response rate). Implicit and explicit ethnic bias favoring NZ Europeans was apparent among medical students. In the CVD vignette, no significant differences in clinical decisionmaking by patient ethnicity were observed. There were also no differential associations by patient ethnicity between any measures of ethnic bias (implicit or explicit) and patient management responses in the CVD vignette. In the depression vignette, some differences in the ranking of recommended treatment options were observed by patient ethnicity and explicit preference for NZ Europeans was associated with increased reporting that NZ European patients would benefit from treatment but not Māori (slope difference 0.34, 95% CI 0.08, 0.60; p = 0. 011), although this was the only significant finding in these analyses. Conclusions: NZ medical students demonstrated ethnic bias, although overall this was not associated with clinical decision-making. This study both adds to the small body of literature internationally on racial/ethnic bias among medical students and provides relevant and important information for medical education on indigenous health and ethnic health inequities in New Zealand.

The Role of Cultural Values in Problem and Prosocial Behavior among --- African-American and European-AmericanChildren With the demographic shifts in the United States, there has been increased attention given to the influence of cultural and ethnic factors upon children's developmental outcomes . Indeed, the U.S. has an increasingly diverse citizenship. Overall, European-Americans continue to be the largest racial-ethnic group accounting for 76.6 percent of all people living in the U.S. African-Americans represent 13.4 percent, Asians 5.8 percent, Latino/Hispanics of all races represent approximately 18.1 percent, and 4.2 percent are classified as Amerian Indian, Alaskan Native, Native Hawaiian or other Pacific Islander, and those with two more races . Additionally, there are approximately 13.2 people in the U.S. who are foreign born. Decades of scholarship have been devoted to examining the modalities by which arriving families retain their native cultural values and begin to adopt the host culture . Adaptation of various immigrant groups have been compounded by their "voluntary" and "involuntary" immigration to the U.S. . These diverse histories, patterns, and the transgenerational transmission of cultural values continue to be salient. Models of acculturation and enculturation are informed by immigrants who with each subsequent generation, embark on a process of integrating the values of their native country with the host culture. These pathways for adapting to the host culture include: assimilationthe declining significance of one's native culture and increasing adoption of the host culture; integration -a multicultural identity embracing aspects of both the native and host cultures; separation -resistance to the host culture and retention of only the native culture; and marginalization/isolation -disconnection from the host or native culture. Acculturative processes have been found to vary with the age of migration to and generational status in the U.S. . Cultural-ecological models emphasize the influential role of adaptation not only for problem behaviors, but also for positive child development, particularly among racial-ethnic minority groups . This paper focuses upon culture conceptualized as shared beliefs, values, customs, and practices that embody the implicitly or explicitly shared ideas about what is good, right, and desirable in a society . Cultural values are viewed as "the bases for the specific norms that tell people what is appropriate in various situations" . Though less work attends to cultural processes for children born in the U.S., the current study draws upon a cultural-ecological perspective to explore cultural values among African-American and European-American children who are more often defined by their presumed race than by their ethnicity . We use both terms in this paper to acknowledge that race and ethnicity can be intertwined in complicated ways . Researchers suggest that societies differ in the degree to which collectivistic and/or individualistic values exist within a given culture . Collectivist societies are understood in terms of the in-group defining and influencing the social behavior of its members with an emphasis on shared experiences, and supporting ingroup members . Identification and solidarity are expected from individuals deemed part of the group, and evaluation of one's actions is tied to the consequences for the in-group . Conversely, individualism is related to the evaluation of one's actions in terms of consequences for the individual. Within more individualistic societies, the emphasis is on uniqueness, independence and competition; personal goals are considered more important than in-group goals . Studies of cultural values frequently include measures of collectivistic and individualistic values . This research has demonstrated that certain cultural values may promote positive development and buffer children from the negative effects of poverty and other stressors . Espousing a family orientation or sense of familism emphasizes closeness, support, and obligations within the family . Fuligni and colleagues examined attitudes toward family obligation among hundreds of firstand second-generation adolescents in several studies . In this program of research, they found that Asian and Latino adolescents retained their parents' familistic values, particularly stronger family obligation values and greater expectations regarding their duty to assist, respect and support their families than did their peers of European-American backgrounds. Tseng found in a large sample of American early adults with Asian Pacific, Latino, African/Afro-Caribbean, and European backgrounds that those who valued family obligations considerably were more motivated academically, but high family behavioral demands evidenced deleterious effects on academic achievement. While valuing family obligations is motivating to immigrant youth, family stress can hinder success. Yet, daily diary studies have revealed that it is possible to navigate multicultural spaces in ways that maintain well-being . While this research points to the importance of familism for youth born outside of the U. S., it would be inappropriate to conclude that family, specifically family closeness, is not important for U.S.-born youth of European heritage. Hardaway and Fuligni found European-American adolescents to be similar to their Asian and Latino peers on family identification and dyadic closeness. For Chinese-, European-, and Mexican-American youth, family interactions and closeness was an important factor in disclosure to their family, and reduced susceptibility to peer drug use . On the other hand, family obligation was related to youth disclosure of behavior for Chinese -and Mexican-American but not European-American adolescents . Thus, different dimensions of family processes emerge as salient for various racial-ethnic groups. In other research comparing immigrant and U.S.-born youth, Phinney, Ong, and Madden found Armenian, Vietnamese, and Mexican recent immigrants rate family obligations as significantly more important than African-American U.S.-born youth, who rated family obligations higher than their European-American U.S.-born counterparts. However, this cannot be construed to mean that European-Americans are singularly individualistic. For example, Wang and Tamis-Lemonda conducted a study that examined the cultural values of parents living in the urban cities of Taiwan and the U.S. and they found that non-Latino, European-American parents emphasized some aspects of individualism but also rated connectedness as important. This research offers some nuanced support for the values of family connectedness and to a lesser degree, family obligation among European-American individuals and more support for these values among immigrant children and youth of color. Nevertheless, the cultural orientation of parents can include a mix of values held dear to them and transmited to their children. Though not always studied under the conceptual framework of familism, there is scholarship dedicated to understanding the importance of kinship, family bonds, and mutual interdependence among African-American families . So often when African-Americans are discussed in the U.S., it is in terms of their presumed race , and not ethnicity or culture . Indeed, the shift in nomenclature to "African-American" was to situate this group in terms of their "involuntary immigration" from countries and cultures of origin . Though an area of controversy, classic work by anthropologists and historians have refuted the premise that the slavery experience resulted in the demise of African-American cultural retentions . In an effort to understand the cultural realms in which African-Americans find themselves, Boykin conceptualized the triple quandary theory including; 1) "mainstream" experience, i.e., more individualistic and competitive beliefs and values common to the majority culture within the U.S.; 2) the "minority" experience that refers to coping strategies and defense mechanisms developed in response to oppression and social stratification; and 3) the "Afro-cultural experience" that refers to cultural aspects such as a value for kinship and extended family ties. In empirical studies of cultural values with African-American adolescent girls, Constantine, Alleyne, Wallace, and Franklin-Jackson found that collectivistic values operationalized as collective work and responsibility, cooperative economics, and selfdetermination, were associated with higher levels of self esteem, perceived social support, and life satisfaction. The results from this study exemplified the process by which collectivistic and individual cultural value orientations may be functional or complementary with support from the group fostering individual development of the girls . Thomas, Townsend, and Belgrave found that collectivistic values were associated with higher psychosocial adjustment including more positive racial-ethnic identity, greater self-esteem, and more positive teacher ratings of child behavior. In a study of the cultural values of African-American upper elementary-age children, students and their parents had significantly stronger preferences for cultural and communal activities at home and at school than for individualistic and competitive activities. However, perceived teacher classroom preferences were significantly higher for individualistic and competitive activities; underscoring the importance of multiple cultural orientations predominant across various contexts . Individualistic and collectivistic cultural values may function relative to various situational contexts. Waterman has argued that some degree of individualism, particularly freedom and the ability to choose, is critical to developing autonomy and agency. In cross-national data of respondents from dozens of countries on multiple continents, individualism has been found to be strongly correlated with subjective well-being and happiness . In studies of adolescent respondents, Schwartz et al. found psychological well-being was positively linked with individualistic values and negatively associated with collectivistic values across gender, first-generation and second-generation immigrants, and the six ethnic groups included in the sample . Thus, some focus on the self has been found to be helpful to well-being. Research conducted by Lam and Zane , among European-American and Asian-American participants ages 17-44 years old, indicated that European-Americans were more individualistic and scored higher in primary control construals versus secondary construals . Research with African-Americans has supported the beneficial function of an individualistic orientation, particularly in terms of "effort optimism," that is, a belief in hard work and sacrifice, and children's motivation to achieve . Thus, some degree of individualism might be functional in the development of a sense of well-being and motivation. On the other hand, a strong individual focus has also been found to be linked to less optimal outcomes. In international research, using data from the World Health Organization across 11-22 Western and non-Western countries, individualistic values were linked to higher rates of suicide, especially for males, . Another potential aspect of individualism includes a materialistic ethos concerned with the acquisition of goods and maximization of profit. Studies have found that people oriented in this way report diminished well-being across various age groups and in several cultures around the world . Second, adolescents high in materialism report more anti-social activities . These results suggest that an inordinate focus on the self is not adaptive. Though there is some research to suggest differences in cultural values by race-ethnicity, this variation is not always in predictable directions. In a nuanced meta-analytic study, European-Americans scored higher on Triandis and Gelfand's more vertical aspects of individualism , whereas African-Americans scored higher in horizontal individualism . In yet another meta-analysis, African-American, Asian, and Latino youth were found to be more collectivistic than European-Americans but, African-Americans were higher than Asian and European Americans in terms of individualism. Thus, as these studies suggest, variation in cultural values may be due to living in a multi-cultural society in which people interact and influence each other in their multiple contexts. Scholars recognize the problems inherent in placing individualism and collectivism into an overly simplistic dichotomy . While some may presume that individualistic and collectivistic values are orthogonal, these values may not be mutually exclusive; both types of values may be espoused within the individual, family, or society , particularly in a multi-cultural society . Tamis-LeMonda and colleagues assert that orientation to individualistic and collectivistic values can be presented along a continuum, and may vary contextually. For example, more individualistic values may manifest at school, while more collectivistic values might manifest at home, in neighborhoods, or faith communitites. While these values may seem opposing, they are not necessarily in conflict with each other. Yamada and Singlelis found that people who were raised in a collectivistic culture and lived in an individualistic culture for several years, were high in both value orientations, were better adjusted, and could deal with adversities more successfully. Nevertheless, aspects of cultural value orientations can be conflicting , additive or functional . We contend that children living in a multi-cultural society, exposed to diverse cultural orientations, may espouse both collectivistic and individualistic values at the individual level, though they may live in an overarching culture that may be more predominantly individually or collectively focused and vice versa . Ecological theories often relegate culture to the 'outer ring' of their concentric circles; constraining the influence of culture on children's development as more distal through its influences on society, policies, and media, which in turn influence families and communities. However, as individuals experience culture, it is a construct that is personal, up-close, and often a proximal influence, affecting daily individual or family practices . --- Summary and Research Aims In the U.S., a country of people from diverse racial-ethnic and cultural backgrounds, previous research has found collectivistic values such as familism and communalism to be beneficial to immigrant and racial-ethnic minority populations, though exorbidant family demands can be stressful and less adaptive. The available research on European-American youth indicates some value of family closeness, though family obligations are less salient for this group. It is important to acknowledge that there is diversity among youth who emanate from across Europe and vary in the importance of family, culture and ethnicity. Subsequent generations of immigrants from Europe may not even think of themselves primarily in racial, ethnic, or cultural terms; Perry refers to this as the "invisibility" of race and culture for young people of European heritage . Race, culture and ethnicity might be more salient to European-American children contingent upon whether they are in a context in which they are the numerical minority . Previous research on African-Americans born in the U.S. affirms their espousal of collectivistic values emphasizing family closeness, community bonding and solidarity but they also espouse some individualistic values, particularly pertinent to the "horizontal" values of autonomy. As research moves away from artificially dichotomizing cultural values, we recognize that some focus on the individual is related to well-being while an inordinate focus on material success has been found to be related to behavioral problems. These findings reflect the complexity of culture in which youth may espouse values, beliefs, and practices from multiple cultural orientations that vary across contexts in ways that are potentially complementary or conflicting . Whereas the vast majority of this work in the U.S. has been conducted with immigrant adolescents, elementary-age children are an often overlooked population. Examining children in young and middle childhood is important because "early starters," those who evidence problem behaviors in early and middle childhood, are at increased risk for delinquency or drug use and generally require more comprehensive interventions . Being aware of one's racial-ethnic group is a developmental task and cultural values may be salient for children even before adolescence . Given the paucity of research on cultural values among elementary school-age children, the primary aim of this study was to examine how collectivistic and individualistic value orientations may be related to risky behaviors and prosocial behaviors among less studied groups of African-American and European-American school age children. The current study examines cultural value orientations of elementary-age children across age/grade, gender, race-ethnicity and how these factors might be related to prosocial and problematic behavior. The specific aims of the current study were as follows: 1) examine the cultural values of individualism and collectivism for African-American and European-American elementary-age children; 2) examine whether cultural values vary with children's race-ethnicity, gender, and grade level ; and 3) explore the degree to which collectivistic and individualistic cultural values are associated with behavioral outcomes for children who vary in gender, grade, and race-ethnicity. --- Method Participants The current data is from Cohort 3 of the LEGACY Together Project, collected in 2011-12, including a sample of 302 1 st -5 th grade elementary school-aged children recruited from 32 afterschool program sites. On average, these afterschool programs were relatively diverse; 16.30% African Amerian, 65.98% European American, 12.05% Latino/a, 3.25% Asian, and 2.42% other-identified. These afterschool program sites were housed in 75 schools that varied in level of urbanicity . Also, the neighborhoods in which these afterschool programs were implemented varied in their level of disadvantage , which is a standardized index of census-based poverty indicators The participating children self-identified as 30% African-American, 47% European American, 6% Latino/a, and 17% mixed race-ethnicity or other; 54% female; and were 7-11 years old . The sample of Latino and mixed race youth was too small for separate analyses; as such, this study focuses on the African-American and European-American children only. Additionally, 15 children were excluded from the current study due to missing data on key study variables. Therefore, the current study includes 219 children, 55% female, 42% African-American and 58% European-American, and the mean age is 8 years old . --- Procedures Consent for parents of children was obtained via letters sent to the home from the afterschool programs to which they could decline their child's participation at any time and their data would be deleted; children were asked to assent prior to conducting the survey. The research team provided password-protected, personal digital assistants for survey completion, which took approximately 45-60 minutes. To make the process more developmentally appropriate and maintain children's attention to the surveys, joke and cartoon breaks were built into the PDAs after each 15-minute section. The survey focused on various dimensions of youth self-perceptions, behavior, and community context, in addition to sections examining youth cultural orientations, the focus of the current study. All study procedures were approved by the university Institutional Review Board. --- Measures The following sections describe the measures. Demographic data were collected and consisted of child gender , grade , age, and raceethnicity . Cultural values.-The Mexican American Cultural Values Scale was used to assess cultural values of individualism and collectivism among Mexican American families in a longitudinal study in Arizona . The current study is the only one we could identify using an African-American and European-American sample with this tested and reliable instrument. Four subscales from the MACVS were used to assess individualistic values and collectivistic values . With our sample, the measure demonstrated acceptable reliability for the subscales of respect , familism , competition, , and material success . Further psychometric information is provided later when discussing construct validity. Child behavioral outcomes.-Children's socio-emotional and behavioral outcomes were assessed using child reports of the Strengths, Difficulties, Questionnaire . The SDQ is comprised of 27 items to which participants responded on a 3-point scale indicating the degree to which each item is "not true, sometimes true, or very true." We modified two of the original 25 items to make the items clearer and unambiguous for elementary children . The SDQ sums and averages the scores on the items resulting in a total score and subscale scores on conduct problems, emotional symptoms, and prosocial behavior. The conduct problem scale included five items . The emotional symptoms scale included six items . The prosocial behavior scale included six items . All subscales demonstrated adequate to high reliability and the childreported SDQ has been found to be congruent with parent reports . Problem behaviors and substance use were assessed by a developmentally-appropriate selfreport measure obtained from Loeber and colleagues' Pittsburgh longitudinal study of delinquency . These items begin by asking children if they know how and where to obtain fairly mundane items like apples or money, progressing to riskier items like cigarettes or alcohol. The subsequent five items, and focus of the current study, assess involvement in experimenting with substances and problem behaviors to which youth could respond yes or no. Items included theft , vandalism , smoking cigarettes, drinking alcohol, and experimenting with marijuana. A count variable was created measuring the total number of problem behaviors for which children reported an affirmative response. Scores ranged from 0 to 7 . --- Data Analysis Missing data analyses were conducted on all variables of interest and showed that only 6% or less of the data was missing on most variables for this sample; approximately 5% of the data was missing for the problem behavior measure. Full information maximum likelihood estimation was used for all analytical models in Mplus . No significant race-ethnicity, gender, or grade level differences were observed between the children that responded and did not respond to the measures of interest. --- Results First, exploratory factor analyses using principal axis factoring and varimax rotation was performed on a 22-item MACVS measure without any constraints. In the initial analyses, the scree plot indicating the number of factors and associated eigenvalues, a proxy for variance accounted for by the factor, suggested a 3 or 4 factor model. The 3-factor EFA suggested 3 factors with most loadings above .40 representing 1) the respect and familism subscales; 2) the material success subscale and one item from the competition and personal achievement subscale; and 3) the competition and personal achievement scale with only two items with loadings over .40. Given that a factor needs to have at least three variables to be considered a factor , factor 3 was considered meaningless. We then conducted a 2-factor EFA . Factor 1, collectivistic values was comprised of the same items as before and explained 32% of the variance. Factor 2, individualistic values, included the material success, competition and personal achievement items and explained 49% of the variance. Two items, one each from the collectivistism and individualism factors, were removed as their factor loadings were below .40 along with an item that cross-loaded on both factors . Next, confirmatory factor analyses was conducted to evaluate the 2factor model fit. Following conventions of Hu and Bentler , which suggestan acceptable fit is indicated by a non-significant chi-square; a comparative fit index of .90 or above; a root mean square error of approximation of .06 or less; and SRMR of .08 or less, this model had an acceptable fit = 243.28, p < .001; RMSEA = .05, CFI =.93; SRMR = .07). Examination of the standardized estimates showed that two items in the collectivistic values factor and two items in the individualistic values factor had very low factor loadings compared to the other items, suggesting that these items were not contributing to their respective factors . Therefore, these items were removed, and a CFA was performed again. This model had a good fit = 135.02, p < .01; RMSEA = .05, CFI =.96; SRMR = .06). Next, multi-group CFAs were performed for the 2-factor model to examine measurement invariance across the African-American and European-American sample. Using the guidelines provided by Muthén and Muthén , the models were first freely estimated such that factor loadings were allowed to vary across the African-American and European-American sample. Next, constrained models were examined in which factor loadings were not allowed to vary across the two racial-ethnic groups. Among African-Americans, the loadings were somewhat higher for 2 items in the familism scale representing family obligations ; the difference between the loadings was .10 -.14. However, the Satorra-Bentler chi-square difference test was not statistically significant suggesting that the 2-factor model of cultural values was invariant, thus measured similarly overall, across the African-American and European-American samples. Table 2 provides descriptive data on all of the key measures in the study including means, standard deviations, internal consistency reliability and preliminary correlational data. Structure Equation Modeling analyses were performed in Mplus v.7 to examine whether cultural values varied by race-ethnicity, gender, and grade and the association of cultural values with behavioral outcomes . Individualistic and collectivistic values were included as latent variables. Findings related to research questions 2 and 3 are presented incrementally, although the comprehensive model was tested simultaneously . Overall, the model had a moderately acceptable fit = 286.33, p < .001; RMSEA =.05, CFI = .94; SRMR = .06). Results showed that European-American children endorsed less individualistic values than African-American children ; however, African-American and European-American children did not significantly differ in their reports of collectivistic values as measured in this study. Boys and girls endorsed similar level of collectivistic and individualistic values. Also, children in 4th and 5th grades reported significantly less individualistic values and more collectivistic values compared to children in 1 st , 2 nd , and 3 rd grades. In terms of the relationships between values and behavior, children who endorsed more collectivistic values reported significantly less problem behaviors . Children who endorsed more individualistic values reported significantly less prosocial behaviors but more conduct problems and delinquent problem behaviors . Additional analyses were performed to examine if the association of cultural values with behavioral outcomes differed between European-American and African American children. First, a model was tested that allowed the paths to vary between groups. Second, a fully constrained model was examined such that all estimates were constrained to be equal across the two groups. The Satorra-Bentler chi-square difference test was not statistically significant , suggesting that the model fit equally well for both groups of students. Therefore, the pattern of associations between cultural values and behavior were similar among African-American and European-American children. --- Discussion The present study was conducted to examine the cultural values of individualism and collectivism for African-American and European-American school-age children; whether these cultural values varied with children's race-ethnicity, gender, and grade level; and to explore the degree to which collectivistic and individualistic cultural values were associated with children's behavioral outcomes taking into account their race-ethnicity, gender, and grade level. Findings demonstrated that we could measure cultural values with reliability and validity across African-American and European-American racial-ethnic groups; however, at the item level, there were some small variations with higher loadings of a few items describing family respect and obligations for African-American children. Nevertheless, these variations were not large enough to result in significantly different conceptualizations of cultural values based upon our exploratory and confirmatory factor analyses. Further, once configured conceptually, all children in the sample were found to endorse collectivism similarly and African-American children actually reported higher levels of individualism. Thus, using these measures of cultural values and youth socio-behavioral outcomes, our findings did not provide support a dichotomous notion of classifying racial-ethnic groups as solely individualistic or collectivistic. Instead, our findings supported the notion that both value orientations can co-exist . Collectivistic and individualistic values were found in both groups and, collectivistic values were associated with more adaptive behavior regardless of race-ethnicity. Supporting Boykin's triple quandry theory, African-American children possessed both individualistic and collectivistic values; they actually indicated higher levels of individualistic values that were less adapatative behaviorally. This finding may be due to the value of competition and material success being stressed in some contexts. For example, previous research has found schools to encourage individual values of competition . Previous research has found a more materialistic emphasis among those who are less-advantaged economically, and this may well be the case in this study . However, given the relationship in our study of individualistic values to problem behaviors for African-American and European-American children, families and other contexts might do well to encourage more collectivistic approaches that help youth to be attuned to the impact of their actions personally and for the group. For the European-American children, this is another example of how they, presumably in an overarching individualistic society, exhibited more collectivistic values at an individual level, albeit items measuring family obligations had lower loadings for this group. It also points to the potential diversity within the group of children labeled as European-American, in this northeastern state where many know the ethnicity of their forebears, they may emanate from groups across Europe that vary in the degree to which family obligations and respect are of import. It is also possible that youth in multi-cultural contexts influence each other in terms of their cultural values. All the children in the sample with more collectivistic values reported engaging in significantly less delinquent problem behaviors. Conversely, children high in an individualistic orientation reported less prosocial behavior, increased conduct problems, and experimentation with drugs and alcohol, vandalism, and theft. Children with an individualistic cultural orientation may be over-focused on themselves and material gain whereas collectivistic children may possess more empathy and awareness of how their actions affect others. The role of age and gender were also examined in this study. Grade differences were observed, with 4th and 5th graders reporting more collectivistic but less individualistic values than children in 1 st , 2 nd , and 3 rd grade. According to Eriksonian theory and cultural perspective-taking theory , older children, regardless of their raceethnicity, may be more collectivistic. As young people grow, they are expected to have less egocentric notions of self and an awareness of others that may be related to collectivism and prosocial behaviors. Based on Gilligan's work on gender socialization and the "care perspective," we posited that girls would demonstrate higher levels of collectivistic orientation due to how girls are socialized to consider the consequences of their actions on others and are expected to exhibit less conduct problems or delinquent behaviors. Surprinsingly however, irrespective of age, girls and boys demonstrated similar levels of collectivistic and individualistic values. In sum, we contend that these data support the belief that collectivism and individualism should be considered with complexity, across culture, gender, and the multiple socio-cultural contexts that influence children's actions, and interactions. While we find collectivistic values to be related to more prosocial behavior, previous research with adolescents has found a more individualistic orientation might foster academic achievement and motivation; an important topic for future exploration given mixed prior research findings in this regard . Based on stage-environment fit models , we contend that children balance these cultural value orientations according to specific contexts . However, in this study, we find collectivtistic values to be more helpful in terms of behavioral outcomes for this sample but future research could also explore relationships with academic and mental health outcomes across multiple contexts. --- Strengths and Limitations These findings indicate that cultural values are significantly related to elementary-age children's behavior. Much of the scholarship examining cultural values with immigrant adolescents and young adults in the U.S. using African-American and European Americans for comparison. We further extend the predominant scholarship to better understand our sample of African-American and European-American elementary-school-aged children in urban, suburban, and rural regions of a northeastern state, supporting the external validity of our findings across a fairly broad group of children. Future work might attend to the potential role of neighborhood structure and interactions in diverse children's endorsement of cultural values, given that neighborhoods are also cultural socialization agents . As with any study, there are limitations, one being the cross-sectional design. Also, our study predominantly uses child self-reported measures, though previous research has demonstrated child self-reports to correspond with other parent and teacher sources . It would be important for future work to examine development and change in cultural values as children age with multiple reports and how this may be related to prosocial and risky behaviors. In terms of exploring developmental effects in future research, it is possible that certain cultural values may be especially important for younger children, but autonomy and individualistic values may play a stronger role in influencing behaviors in later adolescence and adulthood. We acknowledge that our study focused on African-American and European-American children and that the sample of Latino, Asian, Native American and other-identified children in our original dataset was small. Notwithstanding, there are fewer studies examining the cultural values of African-American and European-Americanchildren; all of whom are young people living in increasingly diverse environments. We hope this study will serve as a springboard for other studies examining the role of cultural values for children of diverse ethnic and racial groups across development with implications for future research that examines the role of family and community contexts in cultural socialization and youth. Association of cultural values with children's behavioral outcomes. Note. Coding was as follows: , grade , and raceethnicity . Solid lines represent associations of cultural values with behavioral outcomes; dotted lines represent associations of individual characteristics with cultural values and behavioral outcomes. For ease of representation, marginal and non-significant findings are not shown in this figure. ***p < .001. **p < .05. *p < .05. . --- 54 .00 .57 .01 .53 .01 4. Children should be on their best behavior when visiting homes of friends or relatives .83 -.01 .81 .10 .84 -.08 5. Children should always honor adults and never say bad things about them . --- 69 .04 . --- 62 .14 .74 -.04 6. Children should follow rules, even if they think the rules are unfair . --- 71 .10 .67 .14 .77 .09 7. Children should always be polite when speaking to an adult . --- 75 .00 . --- 68 .06 .82 -.01 8. Children should be taught that it is their duty to care for their parents when their parents get old .60 .20 .68 . --- 23 .54 .15 9. If a relative is having a hard time financially, one should help them out if possible . --- 81 .04 .87 .11 .77 -.07 10. A person should follow rules, even if they think the rules are unfair . --- 71 .07 . --- 73 .18 .69 -.01 11. Older kids should take care of and be role models for their younger brothers and sisters . --- 59 .05 .57 .15 .58 .01 12. Parents should be willing to make great sacrifices to make sure their children have a better life . --- 68 .16 .68 . --- 28 .66 .06 13. The more money one has, the more respect they should get from others .09 .60 .24 .50 -.01 .62 14. Parents should encourage children to do everything better than others .14 . --- 53 .18 . --- 39 .13 .59 15. The best way for a person to feel good about himself/herself is to have a lot of money -.07 .83 -.01 .81 -.14 .84 16. Owning a lot of nice things makes one very happy .13 .51 . --- 23 . --- 51 .06 .46 17. Children should be taught that it is important to have a lot of money .05 . --- 83 .09 . --- 85 .00 --- Conflict of Interest: The authors declare that they have no conflict of interest. ---

Objectives: This study explores the relationships of individualistic (e.g., competition, material success) and collectivistic values (e.g., familism, respect) with risky and prosocial behavior among African-American and European-American youth. While previous work has focused upon immigrant adolescents, this study expands the research exploring cultural values to other racialethnic groups and to a younger developmental period. This study builds upon culture as individually experienced beliefs and practices, potentially espousing multiple cultural orientations and relationships to behavior. Methods: Data from Cohort 3 of a study of 219 urban, suburban, and rural children included African-American (42%) and European-American(58%) children, 54% female, ranging from grades 1-5 (mean age = 9). Multigroup structural equation models were tested resulting in a measurement model that fit similarly across groups (RMSEA=.05, CFI =.94). Results: African-American children reported higher levels of individualism, and African-American and European-American children reported espousing similar levels of collectivism. Children in higher grades were found to be more collectivistic and less individualistic.

Introduction and Background The Affluent Worker is a sociological study by John Goldthorpe and David Lockwood et al. that was published in three volumes in 1968/9 -the fieldwork for which having been carried out in 1962/3. One of its principal conclusions was that the well-paid factory workers it studied far from developing middle class attitudes remained firmly instrumental -wanting good pay for hard, manual labour and being resistant to developing the kind of dispositions and outlooks congruent with middle class careers . 1 Saturday Night and Sunday Morning is a novel by Alan Sillitoe that was published in 1958 featuring episodes in the life of Arthur Seaton. Two years after publication the novel was turned into a successful film starring a young Albert Finney as Arthur. Arthur is a pleasure-seeking Nottingham factory worker who spends a healthy pay packet on his primary enjoyments of wearing smart clothes, of drinking beer and of relishing female company. For Arthur, Saturday night is all: For it was Saturday night, the best and bingiest glad-time of the week, one of the fiftytwo holidays in the slow-turning Big Wheel of the year, a violent preamble to a prostrate Sabbath. Piled-up passions were exploded on Saturday night, and the effect of a week's monotonous graft in the factory was swilled out of your system in a burst of goodwill. You followed the motto of 'be drunk and be happy', kept your crafty arms around female waists, and felt the beer going beneficially down into the elastic capacity of your guts While Arthur Seaton and G&L's affluent worker are not entirely synchronous, they share enough commonality to make a comparison interesting and one that deepens an understanding of the times they represent. 2 The period represented by Saturday Night and Sunday Morning and The Affluent Worker, taken broadly, is that between 1954 and 1963 -a period that began with the end of rationing and ended with the arrival of the Beatles. It was a period characterised by rising wages, low rates of unemployment, steadily improving social services, increasing educational provision, growing job security and a marked rise in disposable income for the working-classes. Also, there must have been considerable reduction in anxiety among much of the adult population for only a dozen years before the start of this period thousands of homes a day were being destroyed by German V rockets . However, while there were marked improvements in the lives of most people in the post-war period things did start from a low base. The 1951 census for England and Wales records that 40 per cent of households did not have a fixed bath, 7 per cent were without a W.C. and 5 per cent did not have piped water. Twenty years later 88 per cent of households had a fixed bath and 87 percent had an internal W.C. . Although the Coronation of 1953 gave a huge boost to the sales of television sets most people watched the event on a set not their own. It was typical in a working-class street for the fortunate owner of a television set to find their small front room packed with friends, relatives and neighbours watching a black and white, eleven-inch screen with rapt attention. It was not until 1960 that 70 per cent of households possessed a television . For the period we are concerned with the last vestiges of wartime austerity were disappearing and a working-class geared to mass consumption was arriving. 3 It was in 1957 that the prime minister Harold Macmillan gave his famous depiction of the period: Let's be frank about it; most of our people have never had it so good. Go around the country, go to the industrial towns, go to the farms, and you will see a state of prosperity such as we have never had in my lifetime -nor indeed ever in the history of this country. What is worrying some of us is, "Is it too good to be true" or perhaps I should say "Is it too good to last?" . 4 During this period the majority of those employed were working-class manual workers. They were in general tightly unionised and predominantly male. It was among such a sample that G&L carried out the study that became The Affluent Worker -a work that established itself as the reference marker for many future discussions of working-class occupational relations. The starting point for the study was to examine the embourgeoisement thesis which argued that growing affluence among the working-class would result in an increasing adoption of bourgeois outlooks and lifestyles. 5 --- The two works The research for The Affluent Worker was carried out during 1962/3 and was, "made up of workers in a number of selected high-wage occupations who were employed at the Luton plants of three major manufacturing concerns" . The firms in question were Vauxhall Motors, the Skefko Ball Bearing Company and Laporte Chemicals. It was the male assembly line workers at Vauxhall that were to form the key sample of manual workers. The importance of the study was that it showed that there was little desire by such workers to acquire middle-class aspirations or middle-class life-styles. The mainly unpleasant work they undertook they did so for instrumental reasons -good wages and job security. Nor were they interested in advancement: "for the large majority of men in our sample the possibility of promotion was of no real significance" . In short the authors conclude, . . . the results of our enquiry are not at all what might have been expected had the thesis of embourgeoisement been a generally valid one" . Additionally the study found that white-collar workers in pursuing their objectives were increasingly shifting away from their traditional non-union stance towards unionisation -in this respect, if decidedly not in others, there was a degree of blue-collar and white-collar convergence. However in both cases this reflected a concern with pay and conditions and did not carry through into left political alignment. 6 For the workers it was their families and their material well-being that was the key tout court to the good life. On the lack of sociality G&L note of their assembly line sample that: Apart from their membership in trade unions and in works clubs -the former being sometimes involuntary and the latter . . . being often merely nominal -our affluent workers prove to have very limited associational attachments. . . . The impression conveyed is very strongly one of husband, wife and children forming together a highly 'individuated' and self-reliant group . . . . Made possible by their good wages these workers often use what little spare time they have on home improvements. This is hardly high living but nonetheless it highlights the feeling of freedom and relief that comes with having money in the pocket and contrasts with the pre-war depression as the experience of Arthur Seaton's parents clearly shows: By God [Arthur's mother] had worked hard and hadn't had a good life until the war, and Arthur knew it. When [Arthur's father's] face grew black for lack of fags she had trotted around to the various shops asking for some on tick till Thursday dole-day. But just as nowadays [he] had endless packets of Woodbines and a TV panel, so she had access to week after week of solid wages that stopped worry at the source . . . . Of his current individuated self Arthur tells a workmate, Jack: Scaled down these comments are not all that far from Zweig's observing in his The Worker in an Affluent Society the emergence of what would later be termed neo-liberal individualism. Talking of the male worker he says: Old slogans, old loyalties tend to leave him cold. The class struggle interests him less and less. . . . Class divisions are still there, but . . .the ethos of class solidarity, of group movement, seems to be weakened, as a man thinks primarily of himself and his home . However perhaps the 'discovery' of new individuated lifestyles in both G&L and Zweig was overdone or was at least not the whole story. In his remarkable The Unprivileged Jeremy Seabrook gives in an account of his own working-class family over four generations a description of a family-focussed, narrowness of outlook and of an experience of abasement that is clearly to some degree generalisable. Upon its publication the Times Educational Supplement regarded it as a, "very beautiful, very bitter book: one of the few works which can be classified as sociology that has the impetus and poetry of a novel" and continued: Seabrook is a member of the first generation [of his family] to question totally and to repudiate the values that embittered and embalmed his family for 100 years. Undereducated, and totally suspicious of everything and everybody, their own particular sort of humour and obstinacy is revealed without mercy. . . . This book should be read by anyone entering teaching or social work who has not really experienced working-class life . Relatedly, Robert Roberts in his The Classic Slum describes the working-class families he grew up amongst as being not only grindingly poor but as seeing and judging the world from an almost exclusively family perspective with no talk of social solidarity: The class struggle as manual workers in general knew it, was apolitical . . . They looked upon it not in any way as a war against the employers but as a perpetual series of engagements in the battle of life itself. . . All in all it was a struggle against the fates, and each family fought it out as best it could . These two examples by Seabrook and Roberts are not intended to show the entire workingclass but only to note that the working-class is not a monolithic entity, nor are the examples given intended to provide any kind of excuse for acute, chronic and unspeakable underprivilege. 7 The trend of family-first and a wariness of others noted by Seabrook, Roberts and others has been a deep-seated feature not only of working-class life, but of all social classes. The individuated, family-focussed working-class identified by G&L and Zweig and others was not a particular feature of the post-war working-class but the continuation of a trait with a long presence . The Affluent Worker was not concerned with the working-class in general but with a predominantly male section of that class. The gradations within the working-class were manystretching from the artisanal respectable working-class with its parlours and impeccable front rooms to the unskilled and deprived working-class living in squalor. Between these two extremes there were many gradations. 8 The Seaton family was somewhere in the middle. They would not have had a special parlour but by the 1950s they were never hungry, certainly far from penniless and not short of provisions. Arthur Seaton regards himself as a harsh individualist who, beyond his family, has no further social obligations. He belongs to a trade union because the union protects him but rejects giving it any ideological allegiance. He takes the growing individualism of the worker noted by G&L and by Zweig to an extreme: he regards both unions and bosses with undifferentiated contempt: Tek them blokes as spout on boxes outside the factory sometimes. I like to hear 'em talk about Russia, about farms and power-stations they've got, because it's interestin', but when they say that when they get in government everybody's got to share and share alike, then that's another thing. I ain't a communist, I tell you. I like 'em though, because they're different from these big fat Tory bastards in parliament. And them Labour bleeders too. They rob our wage packets every week with insurance and income tax and try to tell us it's all for our own good. I know what I'd like to do with the government ). Arthur's individualism is unlike that of the working-class Joe Lampton in John Braine's Room at the Top. The two novels published within a year of each and both to considerable critical acclaim are often bracketed together as foremost examples of the working-class social realist novel. 9 In Room at the Top, Lampton, does all he can to remove himself from his working-class origins. While Seaton like the majority of respondents at G&L's Vauxhall Car factory have no plans to ascend to the middle class Lampton decidedly does, is contemptuous of those who don't, remorselessly and ruthlessly doing anything to join the rich industrial bourgeoisie. In the climb Lampton becomes a local government accountant in a town more prosperous than his own, but it is not enough. As he looks around the town his desires become compounded: I wanted an Aston-Martin, I wanted a three-guinea linen shirt, I wanted a girl with a Riviera suntan -these were my rights I felt, a signed and sealed legacy. . . . I remembered the second-hand Austin Seven which . . . Dufton's Chief Treasurer had just treated himself to. That was the most the local government had to offer me; it wasn't enough. I made my choice then and there. . . . I was going to collect that legacy. It was as clear and compelling as the sense of vocation which doctors and missionaries are supposed to experience, though in my instance, of course, the call ordered me to do good to myself not others . This is far from Arthur Seaton's world of immediacy, hard work and ready gratifications. The idea of Arthur attending evening classes to improve his occupational status is risible. He takes a spartan attitude to his disagreeable working conditions: Arthur walked into a huge corridor, searching an inside pocket for his clocking-in card and noticing, as on every morning since he was fifteen -except for a two-year break in the army -the factory smell of oil-suds, machinery, and shaved steel that surrounded you with an air in which pimples grew and prospered on your face and shoulders, that would have turned you into one big pimple if you did not spend half an hour over the scullery sink every night getting rid of the biggest bastards. What a life, he thought. Hard work and good wages, and a smell all day that turns your guts . --- a u t o b i o g r a p h y r e v i e w . c o m Seaton's world is one of graft and pleasure that also exhibits the deep male chauvinism of its time. He takes great satisfaction in dressing in his pricey clothes, in going out, and in consuming vast amounts of beer. This he especially enjoys in the company of women. Arthur likes women, has no interest in hurting them, and they and he relish the sex they share. Arthur is sleeping with Brenda the wife his workmate, Jack. He likes Jack but he also considers that he deserves being deceived because he is not a man like himself -roguish, good fun and lusty. Large sections of the political left of the period did not find these attitudes agreeable and had considerable problems with the effects of growing affluence and consumerism upon the class they were most keen to represent. To put it simply much of the left intelligentsia, sizeable sections of the Labour Party and assorted Union leaders felt the working-class was not fulfilling its historical mission -of transforming Britain into a society where the workers owned the means of production and were led by a political party informing them of their best interests. As well as this political imperative looking under threat many in the Labour Party and others on the left were, as Dolly Wilson puts it, "fearful of a moral decay associated with affluence, [that] seemed to imply that it was somehow betraying the revolution to want a washing machine" . The Marxisant left's imputed role for the working-class of the 1950s had often little appeal to that very class. As for Arthur Seaton, as Raphael Samuel says, ". . . the hero of Saturday Night and Sunday Morning, is an unashamed hedonist, out to have a good time . . .and about as remote from the self-improving working man of the 19th century as it would be possible to imagine . . ." . Richard Hoggart in his exposé by autobiography and social analysis of mass culture, The Uses of Literacy contrasts the pre-war working-class with the post-war working-class. While noting more hardship among the former he also notes more cultural integrity while amongst latter he observes an increasingly ready acceptance of an unrooted, sensationalist popular culture . 10 The new social effects of a profit-motivated mass culture appealing to cheap thrills was for Hoggart a reason for serious concern -a matter to do with impoverishing the quality of democratic discourse. While well aware of the advantages of a growing prosperity for the working-class he noted, as Ross Cole puts it, that "a 'bloodless revolution' appeared to have taken place, erasing the integrity of working-class culture" . This was not so much a change in working-class political allegiance but was rather a general cheapening of sensibility and attitudes. The criticism of 'mass culture' was common among both the left and right intellectual classes. 11 These reasoned analyses were unlikely to have a noticeable influence on such as the Seaton family or the affluent workers of the Vauxhall assembly line. If Arthur's reaction to affluence is one of self-first his view of gender relations was not greatly different and nor, was it uncommon for the period. He is primarily out for a good time, and little concerned with notions of constancy. Not long into the novel a crisis arises when Brenda finds herself pregnant by Arthur and wants an abortion. Arthur consults his aunt Ada and is supplied with the information needed. The abortion proceeds with the grim necessaries of gin, scalding, water and a zinc bathtub. Brenda is assisted by a friend and Arthur is present, but he and the friend fall out and he leaves the scene and heads off to a pub. When he arrives, there is an amateur entertainer singing badly into a microphone. This annoys Arthur, but not for long because a man approaches the singer and hits him, "dealing him a violent crack on the lower half of his face. . . . Arthur was glad it had happened, laughing so loud that he began to choke from the pain in his ribs" . Arthur looks round and notices Winnie arrive at the pub. She is looking for a friend who turns out not to be there. Arthur offers her a drink: "No," she said, "I've got to get going. I haven't finished cleaning the house up yet for when Bill comes home. He'll be in tomorrow night, and if the house's scruffy he'll have a fit and black my eyes." He persuaded her to sit down. "I'll have a gin-and-orange," she said . Arthur and Winnie drink and talk about Winnie's life, about her husband, and about Brenda, Winnie making it clear that she knows Arthur is her "fancy man". They leave the pub and walk to her house where she ascends the stairs: He followed, loving her on every second stair, loins aching for her small wild body, remembering that he had recently ascended another set of stairs under different circumstances. The evening had begun, and the evening was about to end. She stripped to her underwear and lay in the bed waiting for him. Never had an evening begun so sadly and ended so well, he reflected, peeling off his socks . Violence, as witnessed in the striking of the amateur singer in the pub or Winnie's fear of a beating, is regarded as a way of solving problems by Arthur and his group, and it is violence that symbolically ends the Saturday night of the novel. Arthur is at the annual Nottingham Goose Fair and roistering in his usual anarchic fashion with both Brenda and Winnie in a scene that is both the social realist and picaresque centre point of Saturday Night and Sunday Morning . Arthur is seen by Winnie's squaddie husband and his fellow-soldier friend. Sensing danger, Arthur kicks one the squaddies and disappears. Two nights later, in a graphically described scene the squaddies beat him up. 12 He stumbles into a nearby pub and collapses and is somehow assisted home by Doreen, a single girl he has also been seeing. --- Sunday Morning After several days Doreen visits him in his sick bed. He tells her he was run over by a horse and cart. 13 However he soon comes clean and admits he has been beaten up as a result of his relationships with two married women but adds that he'll put all that behind him. This is not contrition merely that he has decided to absent himself from a dangerous situation. Nonetheless Arthur's Sunday morning has dawned and here we witness not a lessening of his rebelliousness but some customisation to established social practice: As they walked Arthur reflected on the uniqueness of his goings-out with Doreen, on the absence of danger that had tangibly surrounded him when he formerly met Brenda or Winnie. Each outing now was no longer an expedition on which every corner had to be turned with care, every pub considered for the ease of tactical retreat in case of ambush, every step along dark streets with Brenda taken with trepidation. He missed these things with Doreen, so much so that when out with her he felt a tug of excitement at the heart on approaching a corner, and conversation would lapse for a few minutes until they had turned it and he saw with a strange feeling of frustration mixed with relief that an avenue of safety lay before him . Such frissons will remain in the past. Arthur while losing none of his cheek, bravado or fearlessness is nonetheless planning to marry Doreen and move to a newly built council estate. As the novel ends Arthur is alone and out fishing. By contemplating the lives of the fish in the canal he ruminates upon the capricious nature of the fated life -freedom or capture? luck or loss? and is not unaware that like a caught fish he too is hooked -the fish by blind nature and he by social location: With float bobbing before him once more he sat down to wait. This time it was war, and he wanted fish to take home, either to cook in the pan or feed to the cat. It's trouble for you and trouble for me, and all over a piece of bait. And trouble for me it'll be, fighting every day until I die. Why do they make soldiers out of us when we're fighting up to the hilt as it is? Fighting with mothers and wives, landlords and gaffers, coppers, army, government. If it's not one thing it's another, apart from the work we have to do and the way we spend our wages . Arthur Seaton is an affluent worker, and it is that affluence that allows him to live the life he chooses. Although G&L do not investigate in any detail the intimate lives of their respondents it would be wrong to suppose that many of their male respondents led lives quite like that of Arthur Seaton. Arthur is an ideal type representing hedonism, traditionalism and maleness. While these modes of conduct existed before the war it was the economic expansion of the 1950s that allowed male factory workers to enlarge upon them in an unprecedented way. The high-charged documentary expressionism of Saturday Night and Sunday Morning and the studied and considered sociological study by G&L taken together deepen an appreciation of a unique period in British economic history and its most notable representative -the affluent worker. 7. Roberts is unflinching in his account of the capitalist system's cruelties: . . . realists among the old working-class class today remember and with sadness . . . the many women broken and aged with childbearing well before their own youth was done. They remember the spoiled complexions, the mouths full of rotten teeth, the varicose veins, the ignorance of simple hygiene, the intelligence stifled and the endless battle merely to keep clean. Unlike many in the middle and upper classes fondly looking back . . . they weep no tears for the past. . .. The tragedy was that in the most opulent country in the world so many possessed so little . 8. The vast differences within the working-class during this period are well referenced in the material on social class. . The film versions of all four were critical successes. 10. While recognising the value of Hoggart's major study it is clear that Hunslett was not the same as Salford and that working-class experience varied markedly. On this specific issue Robert Roberts notes: Richard Hoggart's personal intimacy with the working-class in its more 'respectable' reaches during the '20s and '30s of the century leads him into praising family unity and 'cosiness'. These qualities, however, do not, I think, appear either so evident or so laudable if one examines the working-class at more levels and over a wider range of time. Certain nineteenth-century traits, of course, ran far into the twentieth and affected longest the ultra-conservative lower working-class -among them, the gulf that stood between parents and children. From family to family there were naturally many variations in its importance, yet this division, I feel, made a profound impression on the minds and social attitudes of millions of manual workers. To ignore its influence is to distort any picture of working-class relationships in the first half of the twentieth century . 11. John Goldthorpe, one of the two primary authors of The Affluent Worker would write some twenty years later: Although in certain respects mass culture might appear aesthetically repellent, to view it in an entirely negative light was seriously mistaken. Dismissive criticism from conservative quarters was often based on fallacious notions of some previous 'golden age' of popular or folk culture from which a supposed decline was traced; while on the left such criticism stemmed largely from the anguish felt at the working-class preference for mass culture over revolutionary praxis . 12. Sillitoe uses the dialect term 'swaddie' for squaddie. 13. This is not quite such a preposterous excuse as it might seem. Horse and carts would not have been an uncommon sight in the Nottingham of the 1950s. --- Author Biography Michael Erben was for many years Director of the Centre for Biography and Education at the University of Southampton . He was a founder member of the BSA Auto/Biography Study Group and has published widely in the area of biographical studies and narrative. His most recent book, co-authored with Hilary Dickinson, is Nostalgia and Auto/Biography. He is now largely retired and is, contentedly, an independent scholar while holding an Honorary Fellowship at the University of Southampton and preparing an extensive study of British postwar lives.

Two, not unconnected, important events, respectively for sociology and literature, occurred during the British post-Second-World-War economic boom. For sociology it was a large, influential study of occupational relations by Goldthorpe and Lockwood et al. entitled The Affluent Worker. For literature it was the highly original, social realist novel of a slice of working-class life by Alan Sillitoe entitled Saturday Night and Sunday Morning. Both these accounts of mainly male working-class lives were not only influential in their time but have remained soeach being separately a reference point for continuing academic study. Additionally, both works noted the importance for individuals of increases in disposable income and the associated pleasurable outcomes. In considering these works together it is not the intention, here, to take either work out of its own vital category or to reduce either to a version of the other but merely to bear in mind Roger Pincott's observation that, "There is no prima facie reason why the literature written in a given society should be less interesting or informative to the sociologist than, say, that society's stratification system" (Pincott, 1970: 177).

IntroductIon Peripheral arterial disease is a clinical manifestation of atherosclerosis, affecting primarily the peripheral vasculature in the lower extremities. 1 In its advanced form, PAD can result in critical limb ischemia or critical limb threatening ischemia. Therefore, early detection and proactive management are critical to patient outcomes. 2 Diagnosis and treatment can be delayed, however, due to the wide spectrum of its clinical presentations. While there are classical PAD symptoms, such as claudication, lower extremity hair loss, and non-healing ulcers or sores of the legs and feet, PAD is complex, and its frequent atypical presentation complicates its management. 3 Furthermore, changes in its definition have contributed to varying estimates of its burden in communities. Nonetheless, recent studies estimate that PAD and its associated conditions affect more than 200 million patients worldwide, and with continued trends in the aging demographic and lifestyle practices in Western culture, the incidence of PAD is predicted to increase. 4 As the incidence and prevalence of PAD continues to increase in the United States, disparities in its diagnosis, treatment, and outcomes have become a major focus point in cardiovascular research. 5 Notably, the disparity in PAD between men and women is an increasing concern. Recent studies have revealed that women are more likely than men to present with latestage PAD and PAD-related complications, such as critical limb ischemia, and are less likely to undergo revascularization procedures. What is less clear, however, are the contributing factors for this disparity. This paper seeks to outline some of the disparities affecting the diagnosis, treatment, and outcomes of PAD between males and females in both Hispanic and non-Hispanic populations. --- Methods One hundred patients were examined during follow up visits for PAD-related care at Texas Tech University Health Sciences Center-University Medical Center in Lubbock, Texas, as a summer initiative to investigate the leading determinants of care affecting patients' access. Patients were previously diagnosed with PAD by history and physical examination, ankle brachial index , arterial doppler, and angiogram. Diagnostic criteria included symptoms, history and physical presentation, and an ABI of less than or equal to 0.90 for symptomatic patients with normal coexisting comorbidities. Patients less than 18 years of age and greater than 90 years of age as well as pregnant women were excluded. These patients gave informed consent for the study with authors conforming to institutional guidelines and ethics. Other information recorded from patient records included demographics , social history , and coexisting comorbidities . Participants were presented with a self-reported survey consisting of two sections. No information on nonrespondents was collected. The first section asked study participants two questions related to gender and ethnicity. Options for gender were male and female . Options for ethnicity were Hispanic and non-Hispanic. The second section consisted of ten interval-based questionnaires with answers on a scale from 1 to 10. These questions related to perceptions on various determinants of care as shown in Table 1. To evaluate patient characteristics, frequencies were reported for categorical variables and mean were reported for continuous variables. Nonparametric χ 2 tests and Fisher's exact tests were used to assess the association of PAD risk factors/comorbidities to gender and ethnicity . To evaluate patient's access to care based on various determinants, part two of the survey consisting of ten questions was analyzed. Each question has a scale from 1 to 10 with 1 being least impactful and 10 being most impactful. Twosample independent t-tests comparing mean results from each question on the survey were used to investigate statistical differences in responses between gender and ethnic groups . All statistical analysis was performed using IBM SPSS Statistics Version 28 and Microsoft 365 Excel Version 2206. P values <0.05 were considered statistically significant. A second set of authors independently reviewed, calculated, analyzed, and rechecked all data to confirm the findings. This research project and the data collected were approved by the Institutional Review Board at Texas Tech University Health Sciences Center, Lubbock, Texas . --- results The 100 patients in this study included 55 men, 45 women, 61 non-Hispanics, and 39 Hispanics. When asked which social determinants of health greatly impacted the patents' access to health care, the lack of transportation and increased work/family obligations were among the highest with women. When separated by ethnicity, Hispanic women reported an additional hurdle to healthcare access involving the existence of language barriers between health care providers and patients . Furthermore, when Values are % and mean ± SD. His F = Hispanic Females; NHis F = Non-Hispanic Females. considering comorbidities, women presented with similar rates of comorbidities as men . --- dIscussIon Our study indicates that numerous barriers and treatment disparities for PAD exist between men and Figure 1. This figure shows distribution of health barriers by ethnicities among women. See Table 1 for determinants. women. These gender disparities emphasize the urgent need for an increased focus on mitigating the barriers that affect both Hispanic and non-Hispanic women. These findings speak to the issues that underlie PAD treatment that warrant further study in patients with PAD. While men have higher rates of comorbidities, women present with similar rates of PAD. Our study appears to be the first to indicate that language and transportation barriers and medication adherence may account for higher prevalence of PAD in women. The most important aspect confirming the gender disparity is the finding that the disparity occurs between non-Hispanic women and men as well as Hispanic women and men. Disparities in PAD care for women affects both minority and general populations, highlighting how ubiquitous this disparity is and the urgent need to address it. The disparities found in PAD treatment also emphasize the need for mass scale education and outreach to women regarding the prevention and care of PAD. It should also include education programs for primary care physicians to understand this disparity to help resolve it. Just as there are nation-wide campaigns to educate the public on heart disease, similar campaigns and outreach efforts must be put forth to target peripheral artery disease and the disparities that affect its diagnosis and treatment. Through these mass outreach efforts, the ultimate goal is that there will be a significant reduction in women presenting to the clinic with PAD-related complications as well as a reduction in PAD-related mortality. This study confirms that PAD disparities affecting women is a major issue, as the differences between non-Hispanic men and non-Hispanic women were similar to the disparity seen between Hispanic men and Hispanic women. It is important to state that the term disparity used in this paper may allude to a connotation of purposeful bias. However, this is not the case in our paper. What we are referring to in our study is simply the differences in the social determinants of health that greatly influence patient care. This topic is recognized as one of the many kinds of disparities that has been commonly described in the current medical literature. --- conclusIon This study identified a notable difference in disparities affecting PAD care between male and female patients. However, while there was a difference between Hispanic men vs Hispanic women and non-Hispanic men vs non-Hispanic women, what was remarkable is that the discrepancy is quite similar with Hispanic women and non-Hispanic women, which indicates that women suffer the most disparities in the overall picture of PAD disparities.

primarily the peripheral vasculature in the lower extremities. In its terminal form, PAD can result in critical limb ischemia with subsequent amputation if inappropriately managed. As the prevalence of PAD continues to rise in the United States, disparities in its incidence and treatment have become a major focus point of cardiovascular research. However, most research efforts thus far have focused on the presentation and treatment of PAD in men. Given that women appear to be just as affected by PAD as men, more emphasis is needed on understanding the disparities and challenges affecting women with PAD. This paper aims to identify disparities in the treatment of PAD between males and females, with a closer look at gender disparities between Hispanic and non-Hispanic patients.

Background Offenders, especially prisoners, have a high prevalence of common mental health problems . Rates of 50-90% for all mental health problems have been found in UK [1,2] and international [3] prison populations, with high levels of unemployment, relationship problems and past trauma [4,5]. Prison has been identified as an opportunity for treatment but release into chaotic community environments poses a challenge for treatment and also research [6]. Critical Time Intervention has been developed and evaluated for prisoners with severe mental illness and shown to have a significant impact at 6 weeks and 6 months post release from prison in terms of increasing engagement with services [7]. No studies have attempted to evaluate such 'through the gate' mental health interventions for prisoners with common mental health problems. In 1996 'Patient or Prisoner' , a Discussion Paper by Her Majesty's Inspectorate of Prisons, highlighted the inadequacies in prison healthcare in England and Wales and argued for equivalence, stating explicitly that prisoners should be entitled to the same level of healthcare as that provided to the general public in the community [8]. Prison mental health in-reach teams were established in England and Wales over the last decade for prisoners with severe and enduring mental illness. However, mental health in-reach services fall short of community equivalence, with wide variation in service provision and that services for common mental health problems in prison are even more limited [9][10][11]. Although the UK government developed the Improving Access to Psychological Therapies for depression and anxiety, these services have been poorly resourced in prisons, with pharmacological interventions often being the only treatment provided [12]. This is despite some evidence that psychological interventions, even 'low intensity' treatments, may be as effective for offenders as they are for the general population [13]. An observational, prospective cohort study evaluating IAPT for prisoners found clinical recovery being achieved in 55% of depression and 52% of anxiety cases [12]. However, while this is similar to results in community IAPT demonstration sites in Newham and Doncaster [14] effect sizes in observational studies do not account for regression to the mean. Discontinuity of care on release from prison is the norm [4]. Once released, ex-prisoners with common mental health problems are, in theory, provided for by mainstream statutory services including general practice and IAPT services. In reality few access these services [6]. Many prisoners with common mental health problems have substantial co-morbidity with personality disorders and substance misuse [2,6] and these offenders may fall between the cracks in service provision between general practice, IAPT and substance misuse services [15][16][17][18]. Offenders are further disadvantaged by their resistance to seeking help and to accepting mental health diagnoses, with lower levels of GP registration and high rates of personal and social problems such as homelessness and relationship difficulties [4][5][6][19][20][21][22]. To address these multiple problems, we have developed a complex collaborative care intervention aimed at supporting male prisoners with common mental health problems near to and following release , working with criminal justice providers , third sector social inclusion services, health services and people with lived experiences , using a range of methodologies [23]. The underpinning principles and practices of ENGAGER are to develop trust and engagement through showing respect and giving practical support; to support mental health through a psychological therapy informed 'shared understanding and action plan' and mentalisationbased approaches which are not disorder specific or based on the ability to turn up for weekly appointments; and to supporting individuals to achieve their personal goals through alignment of personal strengths, family and community resources and joint work with criminal justice, third sector and other health providers. Mentalising is a natural human ability. It is the capacity to think about our own mind and the minds of others and understand how emotions, thoughts, wishes and impulses lie behind and influence our behaviour and the behaviour of others. Good mentalising involves being able to acknowledge that often we do not accurately know what people are thinking and feeling but that often we can make more or less accurate guesses. Good mentalising also involves having an authentic interest in other peoples' emotions and thoughts and not making quick assumptions about why a person may have behaved as they did. For example, rather than assuming why your client has started to drink again, instead being open and curious to exploring with them what was happening for them. Prisons are complex and difficult environments in which to conduct research, and simply getting access can be difficult for researchers. Rigorous evaluation designs such as randomised controlled trials can be challenging to implement without sufficient piloting. In addition, studies following recently released prisoners can be affected by low retention rates [24]. Therefore, for all these reasons, it is essential that trial methods are tested prior to a definitive trial. This pilot trial aimed to investigate whether it was possible to recruit and retain prisoners with common mental health problems in a RCT of the ENGAGER intervention. The specific objectives of the pilot trial were to address feasibility issues and uncertainties about undertaking a definitive RCT of the ENGAGER intervention: inclusion and exclusion criteria, adequate rates of eligibility, consent and randomisation, acceptable rates of participation in the intervention, ability to maintain researcher blinding to trial arm allocation, ability to retain participants at 1 and 3 months post release from prison; and to provide sufficient levels of completion of outcome measures. Success criteria for this pilot trial were to recruit 60 people to the study , to deliver the ENGAGER intervention, and to follow up at least 50% of all participants 3 months after release. In line with the Medical Research Council framework [25] for the development and evaluation of complex interventions, this paper describes the process of the pilot trial and lessons for trial science. --- Methods This external pilot trial is reported in accord with the CONSORT 2010 statement: extension to randomised pilot and feasibility trials . --- Design This pilot study undertook a parallel two-group RCT design with participants allocated to either the ENGAGER intervention or treatment as usual with a parallel mixed methods process evaluation. --- Setting The study took place in two prisons housing adult male prisoners only in two regions of England. --- --- Screening for recruitment into the trial The screening interview was delivered in a narrative conversational format to support rapport building. It incorporated the following standardised screening measures which were read aloud to all participants in order to avoid any potential embarrassment regarding reading difficulties: Patient health questionnaire [26] The PHQ-9 is a nine-item scale for depressive disorder. It asks about feelings of anhedonia, low mood, sleep disturbances, poor appetite, low self-esteem, psychomotor retardation and suicidal ideation in the last 2 weeks. Participants were screened in if they reached a score of 10 or more. --- Generalised Anxiety Disorder [27] The GAD-7 is a seven-item screening tool and severity measure of generalised anxiety disorder; it covers feelings of fear, worry, restlessness and irritability in the last 2 weeks. Participants were screened in if they reached a score of 10 or more. Primary care post-traumatic stress screening scale [28] The PTSD screens whether a person is presenting with PTSD symptoms as a result of a traumatic experience. The scale is based on four main symptoms of PTSD of which three or more had to be present to screen in. --- Past/future common mental health problem identification This screen was developed to capture individuals who may appear well in prison but have struggled with common mental health issues before prison and/or are likely to again after release [29]. It reports whether a person has experienced a common mental health problem including depression, anxiety and post-traumatic stress during the past 2 years which prevented them from functioning normally in everyday tasks, or if they thought this was likely to be a problem for them following release. This screen was adapted further during the pilot to be more stringent as it became evident that many people reported experiencing symptoms in the past only. Therefore, as the pilot progressed, participants were screened in on this only if they had experienced problems compatible with a common mental health problem during the past 2 years, which prevented them from functioning normally in everyday tasks and if they thought this was going to be a problem for them following release. Participants had to screen in on at least one of the four instruments to be included in the study. Participants who screened in were given an additional information sheet, which explained the RCT. The researcher ensured that the potential participant fully understood the randomisation process, and reiterated that participation was voluntary, that they could withdraw at any time and the arrangements to ensure confidently and data protection. Based on our group work with peer researchers, they recommended that we explain the randomisation process to participants as being undertaken by a computer programme, rather than use comparisons with 'flipping a coin' in which human involvement suggests the potential for tampering. Having had the opportunity to discuss their involvement in the study, participants were asked to sign a second consent form if they were willing to take part. The screening interview lasted 15-20 min, and at the end, people were informed if they had screened in or not. People screening in continued straight into the baseline interview and for those screening out this was the end of their participation in the study. --- Baseline interview The baseline interview lasted about 40 min and consisted of a range of different questionnaires and semi-structured interviews administered in order to test them for acceptability for inclusion in the full trial. The testing of these measures and decisions for inclusion in the trial is not reported in this study, but will be reported elsewhere. The baseline interview was administered by the same researcher and delivered in a conversational style. Demographic information was also collected and included information from the following domains: age, ethnicity, education, employment, housing and benefits. Current offence, sentence length and offence history were also collected. --- Randomisation process Participants identified with either current common mental health problems or probable common mental health problems upon release were randomised at a ratio of 2:1 allocation to either ENGAGER plus standard care or standard care alone . To ensure concealment, randomisation was carried out by means of a web-based system developed and maintained by Peninsula Clinical Trials Unit. Communication of randomisation went to the lead researcher at each site, by automatic email. The researcher who performed the screening and baseline interview was blind to the participant's group allocation; a second researcher visited the participant in prison to deliver a letter informing him to which group he been randomised. --- Intervention The ENGAGER intervention sets up a pathway of care up to 12 weeks prior to their release and for 3 to 5 months in the community. The intervention aims to overcome a set of challenges that have been identified as being problematic in this group including: Barriers associated with the transition when leaving prison and re-entering the community The provision of services designed to meet a single diagnostic need or social problem rather than the reality of people with multiple and complex needs Participants' reluctance to trust services During the pilot trial, ENGAGER practitioners and supervisors met these challenges by: Working on individuals' strengths to develop a shared understanding and shared plan addressing their complex needs Adopting a pragmatic therapeutic approach, incorporating a mentalisation-based approach alongside existing skills Release day working, such that each person is met at the gate and taken to their service appointments, accommodation etc. on that day Flexible one-to-one working including use of text messaging, practical support, crisis support and planned therapeutic work Using the full range of resource components-individual strengths, family and community resources, practitioner skills and additional resources/agencies in prison and the community to meet individualised goals Actively liaising with other services such as substance misuse teams, general practitioners and services relating to housing, employment and benefits The Engager supervisor and practitioner meet jointly with the individual on at least two occasions in prison and once in the community to engage with individuals and to develop and review the shared understanding. Engager practitioners meet with individuals at least weekly in prison and the community after release for 8-16 weeks, according to their needs. Practitioners actively review progress, assertively follow up and liaise with others involved in the individual's care and resettlement including families, peer mentors and other agencies and organisations identified in the development of the shared plan. Practitioners plan, work towards and deliver a positive ending. In contrast, treatment as usual consists of general practice contact for some and rarely psychological therapy. Those with opiate addiction are often seen frequently by substance misuse services. --- Treatment as usual group Individuals in the TAU group were able to access primary care, mental health and substance misuse services in the standard way while in prison. They also received support from criminal justice and any other third sector organisations in the standard way in the community. --- Follow-up After the baseline assessment meeting, the same researcher had contact with the participant on at least three further occasions. Throughout this process, attempts were made to maintain blinding to trial arm allocation, and a log was made of occasions when the researcher became aware of it. About a week before the participant's release, a meeting was held; the main objective of which was to strengthen the researcherparticipant relationship and thereby enhance follow-up rates. During this meeting, the researcher confirmed contact information that had been provided during the baseline interview and made any amendments, e.g. where phone number, addresses and contact with services had changed. Participants were then followed up at 1 and 3 months post release by the same researcher. At approximately 1 month post release, the researcher contacted and spoke to the participant either via a phone call or face-to-face. The main objective was again to sustain engagement and plan further contact. At this meeting the researcher discussed the 3-month follow-up in detail and agreed the best way to contact the participant for that appointment. The researcher also obtained any new mobile phone numbers if contact had been made without an up to date mobile contact, or any new addresses or services the person may now be in contact with. The 3-month follow-up took place between 8 and 15 weeks post release, although researchers endeavoured to complete data collection as close to the 3-month point as possible. Researchers normally contacted the participants by phone or via a service they were in contact with, e.g. probation and arranged to meet them at a convenient location in the community. Where possible, interviews were conducted in the premises of services with which the participant was engaging in order to make this as convenient as possible. Where this was not possible, researchers arranged to conduct the interviews in a suitable location in the community and adhered to the Lone Working policy, being accompanied by a 'buddy' as an additional safeguard, if required. As with the baseline data collection, the researcher continued to deliver the follow-up data collection interview using narrative conversational format. The same assessments at baseline were repeated at this follow-up. However, not all participants completed the same outcome measures due to testing a range of outcomes for acceptability for inclusion in the full trial. The results of the testing of these outcome measures and decisions for inclusion in the full trial will be reported elsewhere and no outcome data is reported in this study. All researchers received training in Good Clinical Practice and in the requirements of the study protocol. Joint training for researchers at both sites was undertaken prior to commencing recruitment to the trial to ensure a consistency of approach, from consent to data collection. In addition, weekly team meetings via video conference allowed both research sites to ensure a similar quality. --- Statistical analysis Given the primary feasibility and acceptability objectives of this pilot trial, no within-or between-group inferential comparisons of outcomes were performed. Estimates of recruitment and retention rates and 95% confidence intervals are reported. Descriptive analyses included summaries for participant demographics and baseline characteristics and each outcome baseline and each follow-up. --- Results --- Recruitment to the trial Recruitment commenced in August 2014 and ended in April 2015. Figure 1 shows the participant flow through the study. The records of 864 individuals due for release between September 2014 and April 2015 were examined using prison databases and 21% were identified as eligible, according to sentence length, release date and area, and other exclusion criteria, e.g. risk and severe mental illness. Of these 182 initially eligible individuals, a further 28 were excluded prior to assessment for common mental health problems . Of the remaining 154, 28 declined to meet the researcher and 16 declined to consent after meeting one of the researchers . Thus 110 people consented to take part, all of whom completed the screening interview. Of these, 50 were screened out as not having current common mental health problems or probable common mental health problems upon release. --- Characteristics of pilot trial population A total of 60 participants screened in as having current common mental health problems or probable common mental health problems upon release. Table 1 below shows the mean scores on all assessments and the number and percentage of participants screening in on each assessment. A total of 12 participants screened in on all four assessments, 10 on three assessments, and 18 on two assessments. Twenty participants screened in on just one assessment: none on the GAD-7, one on PTSD, two on the PHQ-9, and 17 on the historical screen. --- Baseline Baseline questionnaires were completed in full for all participants except for one. For this participant it was not possible to complete the screening and baseline Table 2 shows the demographic and baseline characteristics of the pilot sample. The majority of participants were White with an average age of 33 . Unstable accommodation was common with nearly half of participants having spent the majority of time in the last 3 months before coming into prison in some form of temporary accommodation, sofa surfing or homeless and a quarter having lived in more than one type of accommodation in the 3 months before prison. Just over a third had no qualifications and only 1 in 5 participants were in employment in the 3 months before prison. Over 70% had an annual income of less than £7500, with the majority receiving benefits. Over half of the participants had at least one violent index offence, where 'violent' included assault, affray, grievous bodily harm, robbery and possession of an offensive weapon, but not witness intimidation . Only 10% of participants had no previous periods of imprisonment, with the average being six previous periods of imprisonment. Substance misuse was common with 68% self-reporting a drug or alcohol problem and 10 participants reported previous self-harm. The Standard Assessment of Personality [30] was used to identify the possible presence of personality disorder; overall 85% scored 3 or more and 66% scored 5 or more. A score of 3 or more correctly identifies the presence of DSM-IV personality disorder. --- Randomisation Randomisation was carried out successfully. No participants dropped out at the point of randomisation process, i.e. as a result of the group to which they were allocated, indicating acceptability of the randomisation process. One participant was randomised after screening in for the study but before baseline assessments were completed . This participant was then released unexpectedly before baseline assessment could be completed. Maintaining blinding was highly problematic. Despite being given guidance to the contrary, participants shared their status with researchers whom they regularly came across in the close prison environment. In the North West site, by the time participants were due for their 1-month follow-up, the researchers were aware of the trial allocation of all participants. --- Follow-up The overall retention rate was 73% at 1 month [95% CI 60.99-82.86] and 47% at 3 months [95% CI 34.63-59.11]. This included six people who had no/ limited contact with the researchers at 1 month but reengaged at 3 months. For all participants successfully followed up, all outcome data was collected. --- Engagement in the intervention The intervention was delivered to 36 out of the 40 participants allocated to the intervention. Twentyeight of the 36 participants met with their practitioners in the community following their release. In the South West, three participants were released from prison or transferred to other prison establishments before being seen by the practitioners and therefore did not have contact with practitioners while in prison. The other 17 participants received an average of 3.5 contacts each in prison. Thirteen of these participants met with their practitioners in the community with an average of 7.6 contacts . Five of the six participants who were met at the gate continued to have contact with the practitioner in the community. In the North West, one participant decided that the intervention was not for him and did not have any contacts with the practitioners. The other 19 received an average of four contacts each in the prison. Fifteen participants met with their practitioner in the community, having an average of 9.3 contacts (range [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19]. In addition to the abovementioned man who withdrew early on, four participants did not receive any contacts in the community: one of these decided not to continue with the intervention near to release; one was receiving intensive drug rehabilitation and therefore not seen, at the request of the drug rehabilitation service; one stopped responding and returned to a different prison; and one could not be located after a period in hospital. --- Discussion This pilot trial sought to assess whether it was possible to demonstrate acceptable levels of recruitment and retention amongst prison leavers with or likely to have common mental health problems, in order to inform a future randomised controlled trial. It is important to perform pilot feasibility trials when the logistics of a large-scale trial are unclear [31]. There are a limited number of intervention trials within criminal justice settings, and studies conducted in prisons and requiring community follow-ups after release are both rare and particularly problematic. The required number of participants were recruited and randomised within the 9 month timescale set for the pilot trial. Of the people who were assessed for eligibility, the majority were leaving prison to a destination outside the geographical area of where the intervention was delivered. The main trial is addressing this to some an extent, as both the North West and South West sites have extended the release area. In addition, following the introduction of resettlement prisons, prisoners are increasingly likely to be moved to a prison closer to home within the last 6 months of their sentence [32]. These changes should increase the numbers being released to the local area of each prison, and therefore increase eligibility rates. Participation of individuals eligible to be approached and screened was high, with 71% consenting. Of those who declined to take part, the majority were initially approached via the Clinical Studies Officer and not directly by a member of the research team. Feedback from participants approached by the Clinical Studies Officer indicated that they did not really understand why they were being approached by someone not linked to the research. Also being approached directly by the research team enabled questions about the study to be more thoroughly discussed and hence they were better informed about the project. Face-to-face initial approach from the research team is the chosen method of recruitment for the main trial, and recruitment has been shown to be improved by face-to-face consultations [33][34][35]. Of the 110 individuals consented, 55% screened in as having or likely to have common mental health problems on release. Twenty-eight percent screened in on the basis of the historic common mental health question but not the validated questionnaires , raising questions about the appropriateness of this element of the selection process. We have now made changes to the historical common mental health screen by also assessing if participants believe symptoms of common mental health problems are likely to recur following release from prison. Retention of 73% at 1 month demonstrated our ability to follow up after release. The 47% at 3 months was more disappointing, and we have developed further protocols to deal with changes to plans after release. We found that a flexible follow-up window of 4-12 weeks allows researchers to contact and re-engage more participants and we are using this method in the main trial. Researchers will continue to take multiple contact details at baseline for people at high risk of homelessness or transiency, sending several reminders by text message or phone call and offering alternative ways of engaging . Losses to follow-up are likely to be reduced further as researchers will follow up participants out of area and approval has been granted to provide 'thank-you' vouchers at community follow-up sessions. In addition, we are building closer relationships with other involved agencies , including developing information sharing agreements. All of these being methods likely to improve follow-up rates and obtaining consent to contact. Blinding of researchers was a key problem. Participants were keen to share their experiences with the researchers and very often experienced the research and practitioner teams as both representing 'ENGAGER'. To maintain blinding would have required rejecting participants' very practical requests to share contact information and their commitment to 'ENGAGER'. We considered a range of possible solutions to maintain blinding, such as using a paper-based self-complete outcome measure for participants but decided against this strategy due to literacy problems and the likely increase in incomplete data. In the main trial the researchers will know trial arm allocation. This is seen very much as a positive, as it allows for the continued building of rapport between the researcher and participant to facilitate follow-up rates and allows the participant to openly share their experiences. The researchers will deliver the primary outcome measure in a protocolised way to minimise bias. All other measures will be delivered in the more conversational style, which had been developed in order to reduce stress within the research process. In terms of other pilot trial findings: randomisation was accepted and the data completion of outcomes at baseline and follow-up were excellent. Engagement with the intervention, a crucial indicator of viability, was also good exceeding attendance for therapy in IAPT service evaluations [14]. Limitations of the pilot included the use of an outcome dataset which was still being changed and finalised throughout the duration of the pilot. While complete outcome data was collected from all participants successfully followed up, not all participants completed the same outcome measures. The results of the testing of these outcome measures and decisions for inclusion in the definitive trial will be reported elsewhere. Strengths of this study included the use of peer researchers to refine procedures and testing all the key procedures in both prisons proposed for the main trial. --- Conclusion In conclusion, the pilot demonstrated the potential to successfully run a definitive trial. Recruitment is feasible but takes time due to many prison leavers going back to other areas; follow-up is feasible and requires organisation, tenacity and flexibility from researchers; randomisation and collection of outcomes are far less problematic than ensuring researchers are blind to allocation; the ENGAGER intervention was feasible to deliver and acceptable as demonstrated by high levels of engagement. The full trial started in January 2016 . contributed to study design, reviewed and commented on the drafts of the manuscript. CQ and SB were involved in the intervention development and intervention engagement data collection. All authors commented on drafts of the paper. All authors read and approved final manuscript. --- --- Additional file Authors' contributions RB is the chief investigator for the ENGAGER programme and has overall responsibility for the design and implementation of the ENGAGER pilot trial. CL drafted the manuscript and after review by other authors, finalised the text of the manuscript. CL and TK are the ENGAGER trial managers and responsible for the running of the ENGAGER trial. RT, CS, AM, DS and LC are the ENGAGER researchers and recruited participants, collected and entered data. CL, TK, and CG conducted the data analysis. RST is the study statistician. RST, RA, CQ, MM, TH and JS are applicants on the NIHR grant and --- Competing interests The authors declare that they have no competing interests. --- --- ---

Background: Rates of common mental health problems are much higher in prison populations, but access to primary care mental health support falls short of community equivalence. Discontinuity of care on release is the norm and is further complicated by substance use and a range of social problems, e.g. homelessness. To address these problems, we worked with criminal justice, third sector social inclusion services, health services and people with lived experiences (peer researchers), to develop a complex collaborative care intervention aimed at supporting men with common mental health problems near to and following release from prison. This paper describes an external pilot trial to test the feasibility of a full randomised controlled trial. Methods: Eligible individuals with 4 to 16 weeks left to serve were screened to assess for common mental health problems. Participants were then randomised at a ratio of 2:1 allocation to ENGAGER plus standard care (intervention) or standard care alone (treatment as usual). Participants were followed up at 1 and 3 months' post release. Success criteria for this pilot trial were to meet the recruitment target sample size of 60 participants, to follow up at least 50% of participants at 3 months' post release from prison, and to deliver the ENGAGER intervention. Estimates of recruitment and retention rates and 95% confidence intervals (CIs) are reported. Descriptive analyses included summaries (percentages or means) for participant demographics, and baseline characteristics are reported. Results: Recruitment target was met with 60 participants randomised in 9 months. The average retention rates were 73% at 1 month [95% CI 61 to 83] and 47% at 3 months follow-up [95% CI 35 to 59]. Ninety percent of participants allocated to the intervention successfully engaged with a practitioner before release and 70% engaged following release. Conclusions: This pilot confirms the feasibility of conducting a randomised trial for prison leavers with common mental health problems. Based on this pilot study and some minor changes to the trial design and intervention, a full two-centre randomised trial assessing the clinical and cost-effectiveness of the ENGAGER intervention is currently underway.

Introduction 'Fertility treatment' refers to a range of procedures used to assist couples to become pregnant. Treatments vary in intensity and include testing and monitoring of ovulation and semen parameters, medical support of natural conception and assisted reproductive technology . ART includes additional techniques for the medical or surgical manipulation of gametes, zygotes or embryos, including: ovulation induction with clomiphene citrate or gonadotrophins; artificial insemination ; IUI; IVF; gamete intra-Fallopian transfer ; and ICSI . In Australia, fertility treatment is partly or wholly reimbursable under federal benefits schemes, without restrictions on age, number of treatment cycles or existing family size. Australia's comparatively unfettered access to these services provides a unique environment for examining the use of fertility treatments. In 2008, ART treatment was undertaken in 3.3% of all live births in Australia and its use has been increasing by an average of 10% per year for the past 5 years . One reason for this may be that the number of couples deferring starting a family is increasing, with 14.4% of first-time mothers aged 35 years and older in 2008, compared with 9.1% in 1998 . In 2008, according to the Australian and New Zealand Assisted Reproduction Database , 37% of autologous ART cycles were undertaken by women 34 years and younger . Presumably, most of these couples have medical difficulties with fertility other than ovarian failure, which is rare in this age group . Although ANZARD offers considerable information about the per-cycle usage of ART, it supplies little information about the use of ART at the individual level. There is limited information about the use of specific fertility treatments, including non-ART support and OI, which is not recorded in ANZARD unless insemination or IVF is also undertaken. In a 2006 postal survey of women aged 28-33 years, the investigators of the Australian Longitudinal Study of Women's Health found that 17% had tried unsuccessfully for 12 months or longer to become pregnant, of whom 72% had sought help or treatment . ALSWH asked participants whether they used IVF and whether they used 'fertility hormones ', but did not obtain further details. The need for accurate information about fertility treatment use has been highlighted recently by concerns about the safety of some of these hormonal treatments for the mother and baby . Using a cohort study designed specifically to investigate reproductive functioning and fertility of women in their early 30s, we present characteristics of those who experienced difficulty conceiving and those who sought treatment, circumstances underlying such difficulty and type of intervention sought. --- Materials and Methods --- Setting The survey was undertaken in a cohort constructed in 2005 by tracing women born from January 1973 to December 1975 at the Queen Elizabeth Hospital in Adelaide, South Australia . The QEH, a general hospital, was at the time of the sampling frame for the cohort the second largest maternity hospital in the state and served an almost exclusively Caucasian middle-class population. The methods for establishment of this cohort have been described previously . The broad aim of the cohort study was to assess intergenerational transmission of reproductive health problems. The study was approved by the University of Adelaide Human Research Ethics Committee. --- --- Methods All interviews were conducted by trained nurse interviewers, usually face-to-face in the home of the participant. Those who lived out of state or in very remote regions were interviewed by telephone . As part of the reproductive histories, women were asked whether they had ever been pregnant and, if so, to provide details of all outcomes: number of live births, stillbirths, miscarriages, ectopic pregnancies and terminations. For stillbirths, miscarriages and terminations, they were asked the year and duration of the pregnancy. Women were also asked if they had ever been diagnosed with polycystic ovarian syndrome . Women were asked a range of demographic questions including ancestry, parental birthplace, highest level of education and current partnership status. The latter variable was divided into three groups: single ; engaged, married or de facto ; and separated, divorced or widowed. Women were asked about various health-related behaviours, including smoking. Those who smoked more than one cigarette a day were classed as smokers. SES was assessed by applying the 2001 standard SEIFA to the postcode of the participant's residence at the time of interview . --- Outcomes Women who had ever been pregnant, including those pregnant at interview, and who reported one or more miscarriages or stillbirths and no live births were classified as having had only pregnancy loss. Any woman who reported three or more consecutive losses of intrauterine pregnancies before the 28th week of pregnancy was classified as having recurrent pregnancy loss in accordance with the guidelines published by the European Society for Human Reproduction and Embryology . Both those who had been pregnant and those who had never been but had tried to conceive were asked whether they had ever had any difficulty getting pregnant and, if so, were asked to describe the difficulty. Women who reported having difficulty were asked whether they had sought help to assist in becoming pregnant and, if so, were asked to describe the assistance. --- Analysis On the basis of their reproductive histories, women were categorized into four mutually exclusive groups: those who had never tried to conceive and never been pregnant; those had tried to conceive and never been pregnant; those whose pregnancies had all been terminated, who were considered only to have been unintentionally pregnant; and those who had been pregnant at least once without termination, who were considered to have chosen pregnancy . Women in the 'ever chose to be pregnant' and 'ever tried to conceive, never pregnant' groups were deemed to have 'sought pregnancy' and then further classified according to whether they had difficulty conceiving. The subgroup 'ever difficulty conceiving' was then classified according to whether members had ever sought assistance for fertility. Distributions of socio-demographic and reproductive characteristics were compared in the following pairs: only unintentionally pregnant versus ever chose to be pregnant; never versus ever tried to conceive, never pregnant; no versus ever difficulty conceiving; and never versus ever sought assistance. Free-text descriptions were grouped into mutually exclusive categories. Difficulty categories included ovulatory problems , endometriosis, male fertility problems , female anatomic defect , miscarriage, ectopic pregnancy, unknown cause and other . Intervention categories included consultation, tests or education only, ART , AI, medication only, surgery and no intervention. Group differences were assessed using x 2 tests and Fisher's exact test where cells were expected to contain fewer than five members . --- Results Of the 974 women participating, 671 had ever been pregnant and 39 had tried without success to conceive. Nearly all participants were of European ancestry , and the median age at interview was 30.5 years . Table I describes socio-demographic and reproductive characteristics of study participants by conception status. Among women who had never been pregnant , those who had ever tried to conceive were more likely to be currently partnered and were more likely to be overweight than those who had never tried to conceive . Of the 671 who had been pregnant, 53 had terminated all their pregnancies. Compared with women who had ever chosen to be pregnant, women in the only unintentionally pregnant group were less likely to be currently partnered and more likely to have a university degree . Table II shows the characteristics of participants who had sought pregnancy . Nearly a third were smokers . Thirty-nine women had never been pregnant, and a further 48 women had never had a live birth. Of the 618 who had chosen to be pregnant, 160 had experienced one or more pregnancy losses ; 18.8% had lost one pregnancy , 3.2% had lost two and 3.9% had had more than two losses . Sixteen women met the definition of recurrent pregnancy loss. Table II also describes the characteristics of those who had difficulty conceiving , of the subset who sought assistance and of those who did not seek assistance . Those who had difficulty conceiving were more likely to be overweight . Those who had difficulty becoming pregnant were more likely to have lost a pregnancy , to have lost all pregnancies and to have had recurrent pregnancy loss than those without difficulty. Among those who had difficulty becoming pregnant, those who sought assistance to become pregnant were more highly educated and less likely to smoke than those who did not seek assistance. As shown in Table III, of those who had difficulty becoming pregnant, 24 had never become pregnant and another 20 had never had a live birth. Many women with difficulties did not report or did not know the nature of the fertility problem . Of those who had been pregnant and described the nature of the difficulty, miscarriage was common, particularly among women who had never had a live birth . Among those who had had a live birth, ovulatory problems and male fertility problems also featured . Fertility treatments and the young women who use them Nearly three-quarters of those who had difficulty becoming pregnant reported the amount of time they had tried to become pregnant. Of these, nearly a quarter took ,12 months to conceive. Fewer of those who sought assistance reported the time elapsed before seeking assistance. Of these, just under a third sought assistance within 12 months. Two of these were women who had previously been diagnosed with conditions precluding unassisted pregnancy. Table IV shows the type of intervention reported by those who sought assistance. Consultations, tests and education only were common , as was ART , most of which was IVF . Over a third were treated with medication only; close to a third of those seeking treatment were treated with clomiphene only. Two-thirds of women with ovulatory problems were treated medically. Medications used other than clomiphene included metformin, thyroid hormone, unspecified hormones and unidentified medical treatment for hyperprolactinaemia and for endometriosis. The type of provider from whom assistance was sought was most often a specialist indicated by 48 women , followed by a general medical practitioner by 13 women . The type of provider was unspecified for 28 women , 1 woman reported assistance from a chiropractor and 1 woman from a naturopath. --- Discussion In this population-based cohort of 30-to 32-year-old Australian women, a substantial minority reported difficulty becoming pregnant. This figure is higher than self-reported infertility found among women 28-33 years old in the ALSWH and among adults of all ages in the 2006 National Fertility Study , a population-based telephone survey . This difference may reflect differences in questioning around fertility, as our study asked about 'difficulties trying to become pregnant', a more general question than the ALSWH and NFS items specifying the time frame of 12 months. This figure falls within the 6.6-26.4% range of lifetime prevalences of infertility found in resource-rich countries . The majority of those with difficulty sought assistance, despite the slight socio-economic disadvantage suggested by the median SEIFA of 972 . This 57.9% is considerably lower than the 71.7% found in ALSWH, but higher than the 41% reported in the NFS data. However, although few variables are directly comparable between the two papers, ALSWH participants seeking pregnancy were more highly educated than our group , reflecting differences between national and local cohorts, sampling frames between studies and, possibly, between modes of data collection . As we found that more-educated women with difficulties were more likely to seek care, this might well be the primary source of differences between our findings and those of ALSWH. In the global context, our findings were consistent with the average of 56.1% of infertile couples who sought medical care in resource-rich countries . Over half of the young women who reported difficulty did not report or did not know the particular problem underlying the difficulty. This may reflect a general increase in seeking care in anticipation of a reproductive problem among the 'worried well'. The most commonly reported difficulties, where problems were identified, were ovulatory problems, male partner fertility problems and miscarriages. Pregnancy loss was widespread, with over a quarter of those who had become pregnant reporting loss and over 5% losing all pregnancies. All measures of pregnancy loss were significantly higher among women who endorsed difficulty becoming pregnant, suggesting that for some women that expression may include difficulty carrying a pregnancy to viability as well as conceptional difficulties. Alternatively, the act of monitoring for conception may cause some women to notice a loss that might otherwise be mistaken for normal menstruation, and such monitoring may be more frequent among those with difficulties. We found that most women seeking care were treated medically, particularly with clomiphene, rather than with invasive procedures. ALSWH found that 49.6% were treated with hormones or IVF. When our results are framed in those terms, they are very similar, with 47.8% treated with clomiphene only or IVF. Over half of our participants eventually saw medical specialists. This finding is roughly consistent with the 1998-2004 BEACH national study of general practice activity, which found that 45.2% of female infertility problems were referred to a gynaecologist, obstetrician or IVF clinic . A study of similar-aged women conducted in the UK, a nation similar to Australia in infertility prevalence , IVF pricing and health-care delivery system , found that half the couples diagnosed with infertility were offered IVF/ICSI as a first-line treatment, and a quarter were offered OI with clomiphene . It is possible that this higher rate of IVF use arises from differences in referral patterns, treatment guidelines, regulatory environment or study design. Amongst NFS participants, there was a broad lack of understanding about the factors that impact on fertility, such as a woman's age and lifestyle factors . Our findings suggest that at least some of this may stem from a different understanding of 'difficulty becoming pregnant'-the point at which couples seek care may vary substantially by circumstance. Some women sought or were referred to care before meeting the infertility criterion of 12 months trying to conceive, with a few seeking care after just 5 or 6 months. In 2010, changes to the Australian Extended Medicare Safety Net came into effect, capping rebates to ART patients and so potentially increasing out-of-pocket costs to couples seeking assistance . In our study, disadvantage based on the SEIFA score did not vary between those seeking and not seeking assistance, but education, a timeresponsive individual SES measure, did differ. This suggests that patterns of fertility treatment choice are likely to change further in this country. The strengths of this study are its prospective exposure measurement and the sampling frame, which was based on a population birth cohort rather than clients of infertility services. Our participants are broadly representative on a range of socio-economic indicators of SA women of the same age group. Furthermore, our study was structured around examining reproductive health experiences, not specifically infertility treatment, to increase capture of information about women experiencing difficulties but who may not necessarily seek advice or treatment. All of these factors reduce the potential for bias associated with health/treatment-seeking behaviour. One limitation of this study is that the measure of infertility was based on self-reported difficulty conceiving without specifying the minimum duration of difficulty conceiving as 12 months. Although some women reported the length of time taken to conceive, this should be interpreted with caution, as this was not specifically asked of all women. Dick et al. examined differences in reporting of infertility, comparing general questions about problems conceiving with calendar-derived times taken trying to conceive. The results indicated that the general questions were highly specific but had reduced sensitivity , suggesting that they may underestimate true infertility. This would suggest that our finding that a quarter of women aged between 30 and 32 years reported difficulty conceiving may in fact underestimate true difficulties, perhaps enhancing the significance of our results. Nevertheless, the lack of specification of a time frame means that we cannot estimate the prevalence of infertility using the standard definition, making comparability with other studies difficult. Furthermore, in cases where women had ever been pregnant, it was not possible to determine which pregnancies were difficult or had required assistance, meaning that infertility could not be classified as primary or secondary. Nevertheless, reported difficulty becoming pregnant would appear to constitute a common health concern for young women. Women who terminated all their pregnancies were, for the purpose of the present analysis, treated as unintentionally pregnant. This assumption includes women who sought pregnancy but terminated due to fetal anomalies or due to a change in circumstances. However, in both circumstances, this is likely to represent only a small number of women. In 2008, only 2.9% of terminations in SA were attributed to fetal reasons . Similarly, some women who became pregnant and continued their pregnancies undoubtedly conceived unintentionally. It is difficult to estimate the number of women misclassified based on intention to conceive. However, for the present study, it is likely that the denominator of women who sought pregnancy is overestimated, resulting in an underestimate of the proportion of young women having difficulty and seeking assistance in becoming pregnant. When women who terminated all pregnancies were included in the analysis, the findings did not change . --- Conclusions The past few decades have seen a substantial decline in fertility in Australia, partly reflected by fundamental changes in the timing of fertility behaviour. Nevertheless, since 2001, the total national fertility rate has increased, as a result of higher fertility among women aged over 30 years , and possibly because of the contribution of ART to birth rates . Our study identified that almost a quarter of women in their early 30s reported difficulty conceiving. As such, it is critical to continue to document women's reproductive experiences and monitor trends at a local and national level, in both fertility and fertility treatment-seeking behaviour.

background: In Australia, fertility treatment is partly or wholly reimbursable under federal benefits schemes, without restrictions on age, number of treatment cycles or existing family size. In this study, we aimed to characterize the potential need for and use of fertility treatments in a population-based cohort of young Australian women.We conducted structured interviews with 974 members of a cohort constructed by tracing all female infants born at a single general hospital in Adelaide between 1973 and 1975. The main outcome measures were pregnancy history, difficulty becoming pregnant and assistance sought to become pregnant. results: Of 657 women aged 30-32 who had sought pregnancy, 24% reported difficulty becoming pregnant and 26% had lost at least one pregnancy. Ovulatory problems (16%) and male fertility problems (13%) were common among those with difficulty. Over half of the women who had difficulty conceiving (58%) sought assistance, largely from specialists (53%). Consultations, tests and education only were common (22%), as were IVF/ICSI (17%). Close to a third (28%) of those seeking assistance were treated only with clomiphene, as were two-thirds (67%) of women with ovulatory problems. conclusions: In this study, almost a quarter of women in their early 30s reported difficulty conceiving, and over a quarter reported pregnancy loss. This suggests that a significant proportion of young women experience substantial difficulties becoming pregnant. Our findings highlight the need to continue to document the range of women's reproductive experiences and to monitor fertility and treatment-seeking trends.

Background Our current best public health recommendations for mitigation of the COVID-19 pandemic rely on using behavioural interventions such as social distancing and mask wearing, and behaviourally driven acceptance of vaccines to curtail transmission of infection. The success of these policies requires widespread adherence to achieve epidemic control; as with herd immunity, threshold effects in efficacy mean that gaps in adoption can quickly compromise any benefits [1,2]. Therefore, identifying how the adoption of these behaviours is shaped over the course of an epidemic is a key challenge in designing effective mitigation strategies [3][4][5][6]. Adherence, however, relies on individual behavioural choices and so can be complicated to understand and predict [3,7]. Well-established theory from psychology acknowledges that the factors influencing whether or not people take action are complicated [8,9]. Many theories of behaviour and behaviour change have been applied to understanding health behaviour [10]. One of the dominant theories , posits that action is an outcome of interaction between an individual's attitudes and beliefs, their perception of social norms regarding that behaviour, and their perception of their own behavioural control over their actions . In the case of COVID-19, adoption of and adherence to behavioural interventions are therefore likely to be predicated on perception of two main features: a) individual attitudes and beliefs about personal risk of infection and its consequences [13], and b) the social norms around adherence in the individual's community [14]. Over time the changing attitudes and beliefs within each person's network will drive complex, non-linear dynamics in population-level behaviours [15][16][17]. An individual's perception of these features is shaped by communication within their network of friends, neighbours, and community leaders [18,19]. Most likely, the network of a person's close physical contacts, through which they risk infection, differs from their regular communication network of people who contribute to their attitudes and beliefs surrounding preventative behaviours, and from whom they are likely to estimate the social norms of their community. These distinct networks underlie a disconnect between someone's perception of their risk versus their actual risk. On one hand, an individual's communication network could provide early warning of encroaching exposure risks derived from the spread of awareness ahead of the infection itself [20,21]. On the other hand, the mismatch between the communication and infection networks may mean that an individual could underestimate their risk . Despite this, we still understand relatively little about the potential implications of acquiring information from these two different sets of contacts. The dynamics triggered by the spread of awareness through the population are further complicated by the timescales of observable risk due to the etiology of COVID-19. The latency in the development of symptoms and the capacity for presymptomatic, or even asymptomatic, transmission make estimation of real-time risk by surveillance complicated, even without considering different sources of information [22]. In terms of understanding disease prevalence, the relative reliance of individuals in shaping their beliefs, and thus their actions, on their own direct observation of health among their daily physical contact network may have an effect that is distinct from that of their communication network. The balance of these distinct network effects may therefore be the critical feature in determining the success of behavioural public health measures to combat COVID-19. Multiplex networks have commonly been used to quantify complex patterns of social relationships in human societies, including the incorporation of off-and online social ties [23][24][25][26]. Multiplex networks treat different sets of interactions as separate layers within a multilayer network object . Intra-layer edges reflect different types of interaction and inter-layer edges can only connect the same individual in different layers [27]. Individuals can be connected in any number of layers, allowing sets of connections to overlap. By considering multiple, dependent sets of social connections multiplex networks have proved a valuable tool in epidemiological modelling [28][29][30]. We employ a theoretical multiplex network model, implemented stochastically, to test the relative adoption of behavioural interventions in populations of individuals who rely on a) their communication network layer only , b) their physical contact network layer only , and c) both layers simultaneously to inform their understanding of COVID-19, and therefore their individual adherence to protective behaviours such as mask wearing or social distancing. We further consider the influence of structure in both layers of the network and how that structure might impact the behaviour of populations as they rely on perceptions constructed from contacts in those layers. Geographic and social heterogeneity in contact structure are modelled using different levels of modularity . We also consider the potential impact homophily based upon predisposition in either the communication or both layers of the network. While not exhaustive, these studies offer insight into how communities can reinforce the types of informational access that foster protective behavioural decision making among their members. --- Methods --- Overview We used stochastic, theoretical models to test how the awareness of symptomatic neighbours in either a) the set of people that a person who communicates with on a regular basis , b) the set of people that a person is in close proximity to , or c) both of these sets of contacts can impact epidemic spread of an infection with COVID-19 like dynamics. We simulated realistic , multiplex social networks for our populations that coupled a layer of infection-relevant contacts through which the epidemic was simulated and a communication layer through which concern about the disease could simultaneously spread . All modelling was conducted in R3.6.1 [31] and the code used is provided on GitHub . The general modelling framework was the same as that used by Silk et al. [15] and is additionally described in that paper and in the Supplementary Material. --- Population generation We generated populations of 2000 individuals , which consisted of children , young adults and older adults . Age classes could differ in the social connections, epidemiological outcomes and concern about the disease . Individuals also had one of two baseline predispositions and homophily by predisposition impacted patterns of social connections . --- Social network generation We used the same 9 multiplex social networks as detailed in Silk et al. [15]. These were coupled, multiplex networks that connected all individuals within a communication layer that influenced the spread of concern about the disease and an infection layer that influenced the transmission of the pathogen itself . A full description of the algorithm used to generate these networks is provided in the Supplementary Material. For this study, global edge densities were always higher in the infection layer than in the communication layer. The network contained either a) no homophily in either layer, b) homophily in the communication layer, or c) homophily in both layers. Community structure was introduced using a re-wiring algorithm : either the relative modularity of both layers was set to 0.4, both to 0.6, or the infection layer was set to 0.6 and the communication layer to 0.4. Each child was assigned two parents from the same predisposition and community. If children shared one parent they also shared the other but parents could be connected or unconnected. Each young adult formed connections with a number of older adults of the same predisposition as detailed in the Supplementary Material. Children shared the same connections to older adults as their Fig. 1 Illustration of part of a multiplex network from our coupled behavioural-epidemiological models. Multiplex networks enable the representation of distinct, but potentially overlapping, types of social interactions between the same set of individuals. Here we show the communication layer and infection layer from one community within one of our nine multiplex networks. We illustrate the first community from the multiplex network with a relative modularity of 0.6 in both layers and no homophily in either layer parents. When the multiplex network was constructed we re-assigned parents from the infection layer to match those in the communication layer. Child-older adult connections were re-assigned accordingly. --- Concern model We used the same concern model as Silk et al. [15]. Concern about the disease was modelled as a complex contagion [32] through the communication layer. Whether an individual was adherent to mitigation measures or not was based on a Bernoulli draw in which the probability of adherence depended on an underlying trait continuous we term concern. While this simplifying assumption is reasonable for a suite of overlapping protective behaviours, individuals can vary in their adherence to different protective behaviours in reality [33][34][35]. As a result, individuals could fluctuate between adherent or non-adherent states and this was more likely if they had intermediate values of concern. Concern could be influenced by a) Social Construction , b) Reassurance and c) Awareness . For this study the information gained for Awareness could be gained from either the communication layer, the infection layer or both layers. Because an individual is unlikely to find out about the status of every individual in their infection layer, we conducted additional simulations in which there was imperfect detection of symptomatic contacts in the infection layer . We tested 10 values for the strength of the Awareness Effect per day per symptomatic network connection . Values of the Social Construction Effect and Reassurance Effect were drawn from uniform distributions . We selected these parameter values based on our previous model [15]. The concern of children was not modelled. They were assigned as adherent if either or both of their parents were concerned. Each time an individual became adherent they cut connections to a negligible edge weight with a 50% probability within the infection layer while maintaining their connectivity in the communication layer. If an individual became nonadherent then these edge weights returned to their full weight. --- Infectious disease model Our infectious disease model is a very similar stochastic network model to that described in Silk et al. [15] with etiological parameter values adapted from [37,38] and adjusted to match empirical data from the COVID-19 pandemic. Briefly, we adjusted the transmission probability so that, in the absence of behavioural change, approximately 80% of our population would be infected by the epidemic, and set daily probabilities of hospitalisation and death so that outcomes in our model closely approximated those seen during the pandemic . The model contains susceptible , exposed , pre-or mildly symptomatic , symptomatic , hospitalised , recovered and dead compartments. Parameter values are provided in Table S1 and details of the algorithm used are provided in the Supplementary Material. The transition from S to E depended on the number of contacts a susceptible individual had with infected individuals with a pre-defined probability of transmission per contact . Ill and hospitalised individuals cut all their connections in the infection layer to 0.001, meaning that individuals are only likely to spread infection when in compartment I1. The length of time individuals spent in the compartments E, I1, I2 and I3 was drawn from a Poisson distribution with means provided in Table S1. Individuals in the I2 compartment has a daily probability of transitioning to I3 which was dependent on their age . Individuals in I3 had an age-dependent daily probability of dying . --- Simulations For this paper we conducted simulations for the nine multiplex networks described , for 50 values of the Social Construction and Reassurance Effects and 10 values of the Awareness Effect. We then conducted simulations in which the Awareness Effect applied to a) contacts in the communication layers, b) contacts in the infection layer and c) contacts from both layers combined. For scenario b) we repeated the full set of simulations with 0.5, 0.2 and 0.05 probability of symptomatic contacts being detected at each day. This resulted in a total of 27,000 independent simulation runs. In each simulation, individuals were allocated initial values of concern whereby 20% of the adult population would be expected to be adherent at the start of the simulation. For each simulation run we simulated a maximum time period of 300 days or stopped simulations when no individuals were in the E, I1, I2 or I3 compartments. The simulation algorithm was similar to that used in Silk et al. [15] and is detailed in the Supplementary Material. --- Analysis To compare between different runs of the simulations we quantified the height of the epidemic peak at a population level by aggregating the daily counts of symptomatic infections in all 10 communities. This measure of the height of the epidemic peak indicated how successfully each simulated population managed to "flatten the curve" with their adherence to mitigating behaviours [4]. We compare epidemic peaks from when individuals learned about symptomatic network neighbours from different types of social contact while considering values of the Social Construction and Reassurance Effects. To help explain some of the differences between the infection and communication layers in their ability to "flatten the curve" we also examined the similarity of connections in these layers by quantifying the proportion of contacts in each layer that were also present in the other for each multiplex network. --- Results When we assume an individual can identify 100% of symptomatic contacts, the Awareness Effect is more effective in flattening the curve when people respond to illness in their infection layer rather than in their communication layer versus b) in Figs. 2 and3). When this is the case, even relatively weak Awareness Effects can contribute to flattening the curve. Using information from the infection layer alone is nearly as effective as using information from both the infection and communication layers except when the Awareness Effect is very weak and c) in Figs. 2 and3). When social construction is weak there is an important difference, regardless of the strength of the Reassurance Effect . When social construction is instead strong, it plays an important role in flattening the curve except in the case when the Reassurance Effect is also strong, meaning that differences caused by the source of information for the Awareness Effect are only Fig. 2 The relationship between the height of the epidemic peak and strength of the Awareness Effect when Social Construction is weak . An individual learns of symptomatic contacts from a) their communication layer, b) their infection layer and c) both layers together. The colour of points in panels indicates the strength of the Reassurance Effect: yellow indicating a strong Reassurance Effect through to purple indicating a weak Reassurance Effect. In panel d) we contrast the height of the epidemic peak directly for selected values of the Awareness Effect. Boxes indicate the interquartile range, the bold horizontal line the median and the whiskers extend to the full range of the data noticeable when this is the case . Consequently, we focus on the case when Social Construction is weak for subsequent results. A second notable difference that arises when people respond to prevalence in their infection layer rather than the communication layer is that the strength of the Reassurance Effect becomes less important. When individuals respond to illness in their communication layer, the epidemics always have higher peaks with a strong Reassurance Effect even when the Awareness Effect is strong and the curve has been flattened . However, when the Awareness Effect is stronger , learning about illness from the infection layer or both layers results in similar epidemic peaks regardless of the strength of the Reassurance Effect . When we assume that individuals can partially identify the symptomatic contacts in their infection layer, the mitigating effect is reduced considerably in our networks . When there is a 50% chance of an individual detecting an ill neighbour in their infection layer, the height of the epidemic peak remains lower than when an individual gains information on the prevalence of infection from their communication layer, with the difference increasing as the Awareness Effect gets stronger. When there is a 20% chance of detection in the infection layer, the epidemic peak is marginally higher than when information is used from the communication layer with a weak Awareness Effect and slightly lower with a strong Awareness Effect. When there is a 5% chance of detection the mitigating influence of the Awareness Effect is very limited indeed and restricted to strong Awareness Effects. Fig. 3 The relationship between the height of the epidemic peak and strength of the Awareness Effect when Social Construction is strong . An individual learns of symptomatic contacts from a) their communication layer, b) their infection layer and c) both layers together. The colour of points indicates the strength of the Reassurance Effect: yellow indicating a strong Reassurance Effect through to purple indicating a weak Reassurance Effect Fig. 4 The relationship between the height of the epidemic peak and strength of the Awareness Effect when Social Construction is weak . We show the relationship when Awareness is acquired through the communication layer and the infection layer when 100% , 50% , 20% and 5% of symptomatic contacts are detected each day. Boxes indicate the interquartile range, the bold horizontal line the median and the whiskers extend to the full range of the data Fig. 5 The relationship between the height of the epidemic peak and how an individual finds out about symptomatic contacts when the Social Construction Effect is weak for an Awareness Effect of 0.1 plotted separately for each of the nine multiplex networks used in the study. Networks 1-3 have no homophily in either layer, networks 4-6 have homophily in both layers and networks 7-9 have homophily in the communication layer only. In networks 1, 4 and 7 both layers have a relative modularity of 0.4, in networks 2, 5 and 8 both layers have a relative modularity of 0.6, and in networks 3, 6 and 9 the relative modularity of the infection layer is 0.6 and the relative modularity of the communication layer is 0.4. Plots for other Awareness Effects our qualitatively similar The structure of the network was relatively unimportant in determining the success with which populations were able to "flatten the curve" . Most strikingly, there was a small negative impact on the value of information from the communication layer when there was homophily only in that layer and not in the infection layer . When this was the case epidemic peaks remained higher when individuals acquired information on local prevalence from their communication layer. This pattern was driven by their being a greater mismatch between the two layers when there was only homophily in the communication layer; a lower proportion of edges in the infection layer were also present in the communication layer . It is harder, therefore, to flatten the curve when key aspects of structure of communication and infection layers are mismatched and individuals gain information on illness from their communication layer. Otherwise there were no clear and Fig. 6 The proportion of contacts in each layer of the multiplex network that are present in the other layer. Panel a) shows the proportion of infection layer contacts also present in the communication layer and panel b) show the proportion of communication layer contacts also present in the infection layer. Networks 1-3 have no homophily in either layer, networks 4-6 have homophily in both layers and networks 7-9 have homophily in the communication layer only. In networks 1, 4 and 7 both layers have a relative modularity of 0.4, in networks 2, 5 and 8 both layers have a relative modularity of 0.6, and in networks 3, 6 and 9 the relative modularity of the infection layer is 0.6 and the relative modularity of the communication layer is 0.4 consistent patterns related to network structure over the range of structures tested here. Results were qualitatively similar regardless of the strength of the Awareness Effect . --- Discussion Our study helps illustrate that building a perception of infection risk using trusted social contacts can drive community-level patterns of protective behaviours against disease outbreaks, but only plays a substantial role when there is limited information available about the illness of close physical contacts. Accurate information on prevalence in an individual's likely physical contacts is very effective in enabling individuals to construct a reliable perception of their risk of infection and so flatten the epidemic curve when this leads to behaviour change. However, the advantage brought about by an individual's knowledge of the prevalence in their "infection layer" declines very rapidly as the accuracy of this information deteriorates. Homophily in the network can compromise the ability of communities to respond to the actual risk present, especially when it generates mismatches between network layers . These results have strong, direct implications for individuals living in circumstances in which their physical contacts are likely removed from their social spheres of influence. Critically, this pattern reflects large urban centres in which individuals may physically contact many people using public transportation, or riding elevators and moving among offices or apartments in large highrise buildings, but are likely instead to rely on a mostly separate community of family, faith, or recreational activities for social community and conversation from which they will form their perceptions of risks and norms. Of course, this main result relies on the low overlap between contacts present in both the communication and disease layers that shape an individual's perceptions and risks . If those layers were instead identical , then the communication layer and infection layer will be equivalent in the information they provide, meaning that more information is available on local prevalence in an individual's infection layer and so improving the decision-making of individuals based on observations of their personal networks. Our results show that the availability of accurate information from an individual's infection layer is much more effective in mitigating disease spread than using only their communication layer, and that when this is the case using information from both only performs marginally better than using the infection layer alone. However, as the availability of accurate information from the infection layer declines, the success of mitigation declines very rapidly. In our networks, a > 20% chance of detecting each symptomatic neighbour in the infection layer is required for mitigation to be more successful than when individuals use their communication layer alone. The former result suggests that populations comprised of individuals who tend more towards independent risk assessment than towards reliance on community leadership may respond better to public health interventions. However, the latter result indicates the importance of highly accurate information from the infection layer at a community level. Therefore, any social norms that reduce observability of infection in a local community can undercut the efficacy of recommended behavioural interventions. This is especially important in shaping public messaging since both within group density and closeness of beliefs within a community can have less of an impact than the information on which the members of that community rely . Finding ways to provide people more accurate information on infection prevalence among their likely contacts becomes even more important if people are using this information to gauge their personal risk and adjust their behaviour accordingly. We therefore strongly support the adoption of public reports of identified cases in local communities that come into regular potential contact with each other. While this can be challenging to achieve in many societies, and requires sensitivity to personal privacy, regular announcements/reminders at a city, company, school, or neighbourhood level of active disease prevalence can potentially provide critical and effective reinforcement for the individual adoption of behaviours that can protect everyone. One well-established route to providing accurate information about contacts in the infection layer is through manual or digital contact-tracing. These approaches are known to be highly effective in mitigating COVID-19 outbreaks [39][40][41][42], but can be limited by resources or by uptake [43,44]. However, a further alternative is to provide accessible, general information about potential exposure locations. For example, this has formed an integral part of Nova Scotia's effective public health strategy during the current pandemic [45]. It may be that when sufficiently publicised , information on exposure locations is effective through both helping people identify their own potential exposures and also helping people who didn't visit these locations build a more complete perception of their risk of infection that is not apparent through their own social ties. The latter could mean these approaches provide a clear additional benefit to using contact tracing alone where information is less publicly available. Awareness itself is not without complexity. The centralized collection and analysis of data at regional or national scales involves logistical challenges and can cause delay in reporting that information back to the public [46]. It is also frequently the case that communities pay more attention to, and place greater trust in, local sources of information than in more remote sources [47]. Policies that focus on community leadership to ensure a local focus for awareness helps to address both of these difficulties. Our study highlights the need for leaders of social groups to ensure attention is paid to cases of COVID-19 in their community. Their actions can have a positive impact both through providing more accurate information on prevalence within an individual's infection layer and by helping to prevent misperceptions of risk through mismatched layers in an individual's social network. They are also likely to act as influential others that play a disproportionate role in shaping a community's social norms around protective behaviours . Luckily, this is in keeping with the mission of many social groups focused on community support. Communities of worship, social action organizations, and community volunteer groups have all been active participants across the globe in making sure that individuals who are unwell but not so severely impacted as to be hospitalized have access to groceries, medicines, and wellness checks. By actively highlighting the need for these services within their own community, these actions themselves support broader adoption of preventative behaviours and thereby not only help individuals already affected by COVID-19, but actively decrease the likely magnitude of local impacts from the pandemic. A further complication is provided by other learning processes that may influence each individual's behaviour. Our model shows the potential importance of perceived social norms in helping to elevate concern and promote adherence with protective behaviours. When social construction of concern was strong there was a more substantial reduction in epidemic peak, even when individuals learned about their infection risk from their communication layer. However, misperceptions of social norms related to health behaviours have been widely documented, and could potentially impact health behaviour [51,52]. Misperceptions about social norms around protective behaviours in the context of COVID-19 might be expected for various reasons [52]. For example, a common protective behaviour is for people to stay at home . However, once they have adopted these behaviours these adherent citizens are less likely to be encountered by others which could lead to others underestimating concern in their community [52]. Our models also showed that people relaxing their concern from having their social ties in the communication layer healthy impacted the relative value of perceiving infection risk from these same contacts. When the Reassurance Effect was stronger, perceiving direct risk from the communication layer became less effective, especially when individuals played close attention to social norms. When individuals had accurate information from their infection layer instead then the strength of the Reassurance Effect was much less important, indicating that the types of approaches to provide this information discussed above can be important in counteracting erosion in concern over time. While our model provides valuable insights into the influence of how individuals form their perception of risk on epidemic dynamics, we make a number of simplifying assumptions that are important to take into account when interpreting the results. First, we assume that individual adherence to protective behaviours is binary at any one point in time. In reality, non-pharmaceutical interventions consist of a diversity of protective behaviours and if individuals vary in their adherence to different ones it may complicate these results [33][34][35]. Second, while we generated plausible multiplex networks applying these types of modelling approaches will be further enhanced by applying them to data-driven network structures. Empirical data on human contact networks has become available during the current pandemic [53,54] but the ability to combine this with information on other social ties remains a major challenge. Third we made a number of assumptions about how people perceive their risk of infection, respond to information about social norms and what causes reductions in concern over time. The availability of more empirical data related to protective behaviours and behaviour change from the current pandemic can be used to better develop these components of the model and select appropriate theoretical models of behaviour change [10]. --- Conclusions One of the most fundamental challenges in creating effective public health policies is the design of recommendations that will not only achieve theoretical outcomes but will be adopted by enough of a willing public to accomplish those outcomes in the real world. Integrating an understanding of how individual perceptions shape behaviours, and how social context itself shapes perceptions has become one of the critical stumbling points in our local, national, and global response to the COVID-19 pandemic. Our results clearly show that local, accurate, rapid, and trusted information can enable better emergent behaviours. Thankfully, these paths are within the capability of our public health community and local community leadership to provide. --- --- --- --- --- Competing interests The authors declare that they have no competing interests. • fast, convenient online submission • thorough peer review by experienced researchers in your field --- • rapid publication on acceptance • support for research data, including large and complex data types • gold Open Access which fosters wider collaboration and increased citations maximum visibility for your research: over 100M website views per year --- • At BMC, research is always in progress. --- Learn more biomedcentral.com/submissions Ready to submit your research Ready to submit your research ? Choose BMC and benefit from: ? Choose BMC and benefit from: ---

Background: Individual behavioural decisions are responses to a person's perceived social norms that could be shaped by both their physical and social environment. In the context of the COVID-19 pandemic, these environments correspond to epidemiological risk from contacts and the social construction of risk by communication within networks of friends. Understanding the circumstances under which the influence of these different social networks can promote the acceptance of non-pharmaceutical interventions and consequently the adoption of protective behaviours is critical for guiding useful, practical public health messaging. Methods: We explore how information from both physical contact and social communication layers of a multiplex network can contribute to flattening the epidemic curve in a community. Connections in the physical contact layer represent opportunities for transmission, while connections in the communication layer represent social interactions through which individuals may gain information, e.g. messaging friends.We show that maintaining focus on awareness of risk among each individual's physical contacts promotes the greatest reduction in disease spread, but only when an individual is aware of the symptoms of a non-trivial proportion of their physical contacts (~ ≥ 20%). Information from the social communication layer without was less useful when these connections matched less well with physical contacts and contributed little in combination with accurate information from physical contacts.We conclude that maintaining social focus on local outbreak status will allow individuals to structure their perceived social norms appropriately and respond more rapidly when risk increases. Finding ways to relay accurate local information from trusted community leaders could improve mitigation even where more intrusive/costly strategies, such as contact-tracing, are not possible.

Introduction In African societies, values are based on cultural and traditional foundations that vary from one community to another. The celebration of marriage holds religious and customary aspects. This transversality conveys common significance, mainly the transmission of values and beliefs. Marriage in the traditional patriarchal society of Africa is performed with great importance and dignity. With this social practice of marriage comes other traditional customs which are very much indispensable in African society without which marriage is incomplete . On wedding days, women sing traditional songs, not only to show their happiness; but also to educate the bride and bridegroom . --- 126 Published by SCHOLINK INC. All cultures undergo changes, but the residues of culture survive into the civilized area in the forms of traditional songs, games, narratives, and customs . Wedding "involves several ceremonies each of the ceremonies may have its own songs and dance, and other rituals" . From these basic principles, the celebration of marriage had an impact on lyrical songs, promoting interactions on behalf of the customs and habits of a given linguistic community. Based on oral tradition and linguistic facts, the society of the Saloum in the view of others performs a lyrical historical and cultural narrative to convey messages with such wedding songs. The songs or words of marriage transmit pragmatic meaning and moral, religious, and cultural values. --- Problem This article is a pragmatic contribution that aims to discuss the cultural meanings and functions conveyed through song lyrics among the Senegalese people, especially the Saalum community. Thus, two fundamental aspects are highlighted as a traditional aspect from an oral basis and linguistic facts. Otherwise, the language of the wedding songs is essentially based on the oral tradition, leading to making a junction between literature and linguistics. Findings reveal that the majority of Saalum wedding songs focus on motivating the couple, especially, the bride as a pivotal role in this union. An accomplishment that requires the assistance and supervision of parents as mandatories. --- Method Pragmatic analysis of linguistic facts underlines the characteristics of wedding songs that convey a meaning specific to the Saalum. Around twenty elderly Saloum women are taken as key informants, performing the songs of which they had extensive knowledge and experience. The process of data collection includes observation, questions, and focus-group discussions too. The study proceeds to present a collection of songs from which each verse will be translated and pragmatically interpreted. --- Literature Review The important aspect of wedding songs in the society of Saloum mainly considers social, educational, and traditional issues. Indeed, some works have supported such views with songs for these respective purposes. "Wedding songs are generally believed among the Hausa to bring about conformity to the approved modes of behavior regarding married life. For example, there are songs that are instructive as they teach the bride to obey and respect her husband, her parents-in-law, and her husband's close kin. Similarly, there are songs that warn the bride to be careful with her co-wives , and be ready to defend herself from any mischief from them. There are also songs that the bride sings to lament the loss of her girlhood freedom or to praise her intended bridegroom. Likewise, some songs are directed at the would-be husband-in which he is urged to be a good husband by treating his wife fairly and respecting his in-laws . "In African values transmission, wedding ceremonies became one of its main functions. During these occasions, life skills and knowledge about married life were shared with the young couple through jangwa songs" . "Members of a community engage in group singing as part of organized activities with specific functions, where knowledge is shared through songs" . Many daily social issues are taught and followed thanks to these songs, in which the traditions are ruled in. --- The Oral Basis of African Wedding Songs Riggs describes African marriage as a combination of religious and traditional practices. It is clear that religious marriage ceremonies also follow traditional practices adopted by communities. Tradition has an important aspect that the orality underlines. Many authors and researchers have marked this traditional importance in African marriage. "We are Ibos. When we want to marry an Ibo girl, we follow the Ibo custom to connect with the parents." This implies a need to take root and embrace the girl's parents. Moreover, the same author points out that Obi Okonkwo, who studied in England and moved to Lagos to work, rejects the weight of the custom that forbids her to marry Clara who is "Osu", that is to say, a caste class. "Osu is like "leprosy" in people's minds. So, the strength of tradition imposes all its rigidity . According to Jagua Nana, the heroine of the novel of the same title, her short marriage is an attempt to force her to conform to the customs and traditions of Ogabu . Indeed, literature has always been a part of the oral basis, leading to putting a connection between theories and orality. With regard to Negro-African literature, a distinction should be made between "works written in European languages and oral literature that is expressed in African languages" . Indeed, traditional African literature is understood mainly by its oral character. It constitutes literature through which speech plays a fundamental role in the transmission of socio-cultural values from one generation to the next. Thus, "The inexhaustible source of interpretations of the cosmos, beliefs and cults, laws and customs; systems of kinship and alliance; systems of production and distribution of goods; modes of political power and social stratification; ethical and aesthetic criteria; concepts of representations of moral values" . "Speech conveys many values in traditional African society" . The word remains […] the priority and majority cultural support par excellence in so far as it expresses its traditional heritage and weaves between past and present generations. This link of continuity and solidarity is without which there is neither history nor civilization . In summary, tradition and customs practice does not exclude anyone regardless of social or financial standing. All these ideas reflect, among other things, the importance of oral literature, whose study 128 Published by SCHOLINK INC. makes a junction with the lyrical songs of marriage, in which semantic characteristics are set. --- Results The wedding songs in the Saloum are governed by a playful and moral eloquence in view to the participants and actors. Indeed, women who have experienced these traditional requirements in the sacred unions explain to their younger generation the need to follow their steps and successfully prepare themselves as they did. Those people involved in these cultural practices find that the worshiping conditions should be adapted to social needs. These songs reflect all the devotion that a woman must show to keep her home safe. An extract of the songs is drawn for semantic studies in a glozing corpus. --- Discussion According to the oral tradition, African children generally follow the rules taught through songs, proverbs, tales, riddles, etc. This allows the young generation not only to acquire knowledge, but also transmit it to the next generation. Since children had been raised under their parents' attention and care, they must understand how to follow their steps. As such, the traditional realities made people prepare for their marital life while referring to the elders' instructions. The couples have reached the level of wise behavior, especially, the women who care about the bonds of marriage. Saalum marriage like other communities has taken a way for people to perpetuate their bloodline, but also the sacrality of bounding links into families and relatives, while keeping rigorously these links. Indeed, the pragmatic aspects reveal that women are guiding the relatives' connection for wider links relations. Those who are lost with the nature of the relationship among relatives refer to the women who guide them. Many roles and ideas are drawn from these songs and the meaning has been pragmatically interpreted. --- Women as --- Dañu lay naxee ba yòbbu la, soo demee yaadi rooti taxanee, Dañu lay naxee ba yòbbu la, soo demee yaadi sákki laalo. "They mollify you for the only goal at bringing you in a marital home, as soon as you reach in, you become the gooey food fetcher" As the part of the song outlines, sadness reveals a hidden reality. The words point out a sad mother for marrying her daughter with no choice. In fact, the tears of a mother do not only mean giving her daughter in marriage as a loss but also the awareness of the sacrifice she will do in her household. In fact, women undergo chores in their homes to provide services to the members of the in-laws' family in all situations. Whether the sun is hot or it rains, sooner or later, the good African woman is always the one who faces these moments. Indeed, based on kinship guidance, is noted in the wedding songs that women hold main roles in the societies' settings and rules. The supremacy of the family is held by the woman thanks to her devotion to fertility. Her ability to produce her descendants within her marriage is the main issue of her strengths. --- Women as Thus, the song illustrates the sacrifice she must face to reach such a level of fertility. Allowing her to rest in an estimated period, while gaining respect and appreciation of her in-laws. "In Africa, The reproductive capacity of women is a major assurance of permanence and stability in marriage, in the family, and in the clan. This vision is manifested in the characters of 'Idu and Adiewere' who were entirely devoted to their union. Their happiness appears as ecstasy but unfortunately slows down by an absence of fertility" . Nwapa lets us understand that in the African tribe, motherhood holds a prominent role, and prior is given to submissive and perfect mothers. We understand from these lyric words, the faith of a heavy destiny in the lives of women who bear such responsibility. --- Women as Family Bonds 7. Fonkal sa sey doom sa moomeel, boo nekee jeegu puso yaadi defar. "Take care of your household as your ownership my daughter, If you become a relative bonder, you will be the wellness-maker." The song reveals that despite fertility as a core purpose in marriages, the behavior of the wives is considered to be the main principle to link the in-law families. Women are devoted to their kinship as well as one of their in-laws, due to the descendants she cares for. Women who will care for their children will care for their in-laws too. This is why, through these wedding songs, prior is given to women leadership as social characters. Otherwise, the woman holds a great responsibility to keep the 131 Published by SCHOLINK INC. two families united while ensuring good relations between them. The wife has an outstanding role in family decision-fulfillment. Indeed, the wives are mainly implicated. In the Saalum community, the goals of the wedding songs judge the personality of the women based on their actions. Indeed, the woman is the bride who leaves her home to join her husband and in-laws home to care for the alliance of both families. It is thus understood that women more often return to neighborly families and relatives to strengthen ties of blood and sometimes brotherhood. --- Women as House Managers 8. Jagal, jagal doom nga jagal, bu jagee nga am lu leer ci jagal. "Restore restore my daughter restore, If you restore breaking you will possess bright things." Wedding songs are considered the art to dance when women illustrate the ability to move and create social attractiveness. Such facts would indicate a willingness to impose themselves and manage what belongs to them in their household. Thus, such strategies would participate in the good household and husbands' management and similarly transmit the skills to her property. Apart from human resources, women generally hold economic activities in their households as livestock, agriculture, and trading. Management skills are helpful for them in such a business. Economically, the women who own cattle learn to manage them with the aim of creating and expanding wealth. The words teach women not only to care for their owners but also to be able to restore any of this which would fall into breaking. --- Marriage As a Means of Priesthood and Education --- Waaye na nga sàlloo ngor ak jom ca waar wa, Sàllool ngor ak jom ca waar wa. "But, put up with dignity and self-respect in the issue, Put up with dignity and self-respect." The priesthood of marriage in the Saalum context concerns main women as union savers and family carers. An alleged judgment against the woman in her devotion would justify the neglect of her property. This implies that eventual mistakes would be the cause of the disunity of the in-laws' families, as well as her children. Besides, obedience also becomes an important character of the woman to accomplish her dogma. If a woman proves evidence of obedience, she will make satisfied with the choice made upon her. From this submission, love or desire would be based on a target union, conceived by parents or elders. Marriage, therefore, requires patience, support, and motivation to succeed in such a priesthood union. Considering the above arguments, sustaining the problem of this research paper; it must be known that the involvement of parents in traditional marriages plays a fundamental role in their success as well as their failure. The marriage of an African woman, whatever the conditions, is bound to the instructions of the parents. Indeed, parents are taken as the backbone of the union of their children. This is why girls mostly accept the choice of their parents with no objection. At last, one might notice that obedience and self-denial are fundamental characteristics of housewives. This is the reality that all young African women, as part of families of standard morality must take into account. From this point of view, marriage becomes a priesthood that requires a good educational and moral basis to assume it. The household reconstruction is based on moral and cultural principles adapted to social norms, which often excludes the desire to love before getting engaged in a couple. One mere remain connected to social realities to make progress in such unions. This is the main idea that wedding songs give, although they hold different themes. The semantic aspect is set as a topic issue, leading to emphasize the song's message, transmitted from the old to the young generation in Wolof society, especially in the Saloum community. Thus, the songs of marriage in such a context are purely motivational and conservative, and the words are facts of evidence. All this knowledge is taught thanks to the songs' Semantics, leading to enriching cultural diversity and traditional beliefs within the community of Saalum. Thus, the Semantics of the wedding songs bear messages, wisdom, and sacrifice toward couples, especially women. Pragmatic analysis of songs has led to conveying messages, educating young people, expanding knowledge in future generations, securing social relationships, and managing resources. We understand some basic virtues behind these unions planned by old people to care for their living and beliefs. This old practice of wedding songs has basically founded traditional societies with human civilizations. Similar to neighboring cultures, the wedding songs govern the will and parental decisions. This implies much responsibility and motivation towards the concerned couples. However, this pragmatic sense of traditional marriage embodied in songs does not exclude contentment in some other cases. Indeed, it exists through these unions couples who mutually loved each other and receive the parents' care for their unions. Some people engage naturally in a couple of relationships among relatives or neighbors without having one's parents' arrangement. But parents are always ready to assist such unions for success. Such facts lead to understanding the crucial decisions of parents in these unions, who aim to maintain family relationships, ethnicity, or social belonging. This tendency to accept a conjoint for the purpose of maintaining or strengthening family or ethnic relations may reverse depending on moods, faults, or even misconduct of the couple. Culturally, sacredness is taken into account to solve any eventual issues raised by the unions. --- The Study Objectives The issues of cultural identity and beliefs are set in the African world where their practices are bound to social norms and realities. This study shows a short link between religion and culture as being essential parts of human existence. Indeed, through songs and other oral basis, people are mainly bound to such cultural beliefs, while preserving their religious instructions in the management of marriages in traditional societies. These pragmatic meanings of the wedding songs have given wide aspects in African civilization, based on moral principles as well as values. Moreover, this topic issues contributes to cultural diversity, allowing people from different geographic areas to apprehend other cultures around the world. It also expands cultural knowledge, leading to a better understanding of people's beliefs within different communities. --- Findings African people have developed some beliefs and practices based on tradition to perpetuate them. We expect from this topic issue a desire to give women the leadership of self-engagement in couples, without hampering their happiness. Indeed, some developed ideas around the issues of marriage as being only sacerdotal and donation are mainly developed in tradition to charge women. Therefore, marriage is seen as a commitment of women who endeavor in their household. Besides, the responsibility given to women as union carers and savers thanks to their devotion should be shared by husbands and in-laws as well. Many theories led to the understanding that the failure of marriage in Africa is under the responsibility of women so that, they put up with all situations. As a result, some ideas and thoughts were developed in traditional African society about the dedication and sacrifice of women to save arranged or sponsored marriages. Among these theories, are cited proverbs, riddles, tales, songs, etc. which this topic has treated. Thus, the community established songs, likely to characterize the feeling of grief, proudly expressed to manage hardship and keep the tradition. These criteria of marriage, although considered as irresistible to some, are perceived as the foundations of a social responsibility, conveyed by responsible people. --- Conclusion The African Oral Tradition has much cultural diversity due to the facts of social norms related to the historical context of the African marriage. Wedding songs convey particular messages. The importance of such a practice would justify the adoption of traditional and societal values, namely, respect for elders, their speech, respectability, personality, and wisdom. Thus, songs have a crucial role in building societal values, creating relations, educating young people, etc. based on conventional rules. Apart from marriage themes, other topic issues have been raised from the same context. The topic issue has thus considered wide aspects of the marriage in which the pragmatics reveals through such song.

This study raises women's issues that are part of women's lives. It draws particularly the wedding songs pragmatics in societies in which communication is an oral cultural basis. From these views, the topic elaborates cultural perception of a certain community, regarding wedding songs to illustrate a handful of characteristics of civilized rules held by the tradition. This topic treats from the view of pragmatic meaning the problem of wedding songs in which, an extracted version is taken from informants to analyze the impact of these oral communication characteristics. Pragmatically, the analysis has thus outlined many communicative aspects to convey knowledge, to inherit social and cultural practices, and to educate the young generation, while serving adults as guides. This topic contributes to cultural diversity and traditional apprehension around different concepts in African societies generally, and the Saalum community particularly.

total number of COVID patients who were admitted in the hospital divided by the total number of beds in each center and multiplied by the new COVID admitted in the hospital. Comparisons among groups were made using t-Student for normal continuous variables. Wilcoxon signed-rank test for non-normal continuous variables and chi-square test was used for categorical variables. Follow-up started at the time of admission. Predictors of the outcomes were explored through generalized linear mixed-effects models, using center as random effect. Measures of association were expressed as odds ratio , with a 95% confidence interval , adjusted for variables p<0.10 in the univariable analysis. Statistically significant differences were considered two-side p-value less than 0.05 or if OR 95% CI excluded 1. Data analysis was performed using R statistical software. --- RESULTS There were 5,235 patients included in the analysis. 44% of the patients were female and median age was 68 . 3391 patients were from Madrid and 1844 were from Barcelona. Mortality and ICU admission rates were 15.9% and 6.2% respectively . Regarding birthplace 4288 patients were born in occidental countries, 840 were born in Latin America and 98 in other regions. 20% of the patients of patients were immigrants, being 80% of them from Latin America. Latin American patients were younger but no differences were found in sex. In univariable analysis it was shown that patients who were born in Latin America 1.58-fold ICU admission rates than their Occidental born counterparts but a decrease in mortality rates . After multivariable analysis adjusted by age, sex, per capita income, population density, hospital experience, center and hospital saturation, patients born in Latin American countries were found to have an increase in ICU admission rates but no differences were found in the same model regarding mortality . --- DISCUSSION Amongst hospitalized patients, we found significant increased odds of ICU admission for patients who were born in Latin-American countries. Although these cluster of patients showed a trend towards more mortality rates, this association was non statistically significant. Our study is in line with the emerging evidence which suggest socially disfavored communities have poorer COV-ID-19 clinical outcomes. As ICU is a surrogate marker of critical illness, present study suggests that the disease in Latin American population may be more severe, which may not impact in mortality because this subset of population is younger. Findings have to be interpreted in the context of Spanish social structure, where Latin American population constitutes --- INTRODUCTION Social determinants are important causes which can affect health [1,2]. This has been demonstrated to have a great importance in infectious diseases [3], where the interaction between the exposition to the microorganism and the health status are crucial to produce the disease. Social inequality is the situation when resources are allocated unevenly, which generates patterns across socially defined categories of persons, such as ethnicity, gender or age. Social inequality determines a social vulnerability to the disease for each group, defined as risk exposure and capacity to recover for a community which is highly determined by income, work and access to healthcare system. According to the UNDESA world social report, inequality has increased in most developed countries since 1990 [4]. In Spain, after the financial crisis of 2008, people at risk of poverty or social exclusion increased in two points from 2007 to 2019, while in the rest of Euro area remained stable [5]. With the global spread of COVID-19, studies in the US and UK have shown that certain communities have been strongly impacted by COVID-19 in terms of incidence and mortality [6]. While this relationship has been studied in Spain at aggregated level in Barcelona [7], no other social determinants of health apart from income have been studied in Spain. The objective of the study was to determine social determinants of health among COVID-19 patients hospitalized in the two major cities of Spain. --- MATERIAL AND METHODS A multicentered retrospective case series study was performed collecting administrative databases of all COVID-19 patients ³18 years belonging to hospital area. Two centers in Madrid and two in Barcelona participated in the study collecting data from 1 st March to 15th April 2020. All patients were followed until the 1 st June 2020. We included all patients with a confirmed or high suspicion diagnosis for COVID-19. From administrative databases we obtained age, gender, birthplace, and residence ZIP code. Patients who were born out of Spain were considered as immigrants and they were grouped into three categories: Latin American origin, Western countries different than Spain and other . From ZIP code we obtained per capita income of the area were each patient lived form the National Statistics Institute of Spanish Statistical Office . These geographical variables were obtained at census level and then merged into ZIP code via QGIS . QGIS Geographic Information System. Open Source Geospatial Foundation Project. http://qgis.osgeo.org). Hospital experience was defined as the number of COVID patients attended each day in the center during the study period. Hospital experience was calculated for each day and applied during the period were the patient was admitted. Saturation index was calculated as the the main immigrant and minoritized community. While other studies have tried to explain outcome disparities in different ethnical communities due to biological differences, modern scholarship regards race as a social construct which is just a weak proxy for genetic diversity [8]. Although outcomes in our study were adjusted by income, several determinants such as education, employment and cultural differences in access to healthcare remain uncontrolled to affirm such differences in severity are attributable to biological factors. Therefore more studies in this direction are needed to provide more evidence. COVID-19 severity varies widely [9,10], not only depending on biological but also socio-economic factors. With the emerging evidence that this subset of population is at higher risk of poorer outcomes, targeted public health strategies and studies are needed. --- FUNDING None to declare --- CONFLICTS OF INTEREST The authors declare that they have no conflict of interest

Introducción. Con la propagación mundial de COVID-19, estudios de EE. UU y Reino Unido han demostrado que ciertas comunidades se han visto fuertemente afectadas por COVID-19 en términos de incidencia y mortalidad. El objetivo del estudio fue identificar los determinantes sociales que pudieran condicionar los resultados en salud en pacientes con COVID-19 hospitalizados en las dos principales ciudades de España.Se realizó un estudio multicéntrico retrospectivo de series de casos recogiendo las variables de las bases de datos administrativas de todos los pacientes COVID-19 ≥18 años pertenecientes a dos centros de Madrid y dos de Barcelona (España) y evaluados de 1 de marzo al 15 de abril de 2020. Las variables obtenidas fueron la edad, sexo, lugar de nacimiento y código postal de residencia. A partir del código postal obtuvimos la renta per cápita de la zona. Los predictores de los resultados se exploraron a través de modelos lineales generalizados de efectos mixtos, utilizando el centro como efecto aleatorio. Resultados. Se incluyeron 5.235 pacientes en el análisis. Después de un análisis multivariable ajustado por edad, sexo, ingreso per cápita, densidad de población, experiencia hospitalaria, centro y saturación hospitalaria, se encontró que los pacientes nacidos en países de América Latina tenían un aumento en las tasas de ingreso en la UCI (OR 1,56 [1,15], p <0,01), pero no se encontraron diferencias en el mismo modelo con respecto a la mortalidad (OR 1,35 [0,92], p = 0,09). Conclusiones. La gravedad de COVID-19 varía ampliamente, no solo según factores biológicos sino también socioeconómicos. Con la evidencia emergente de que este subconjunto de población tiene un mayor riesgo de peores resultados, se necesitan estrategias y estudios específicos de salud pública.

moral judgment and decision-making remain highly debated and extant findings are contradictory 20 . At a general level, moral decision-making is rooted in the concept of human morality, which could be defined as "a collection of biological and cultural solutions to the problems of cooperation recurrent in human social life" . This implies that morality is essential for promoting collaboration [22][23][24][25] , but also that when individuals engage in moral decision-making, they not only consider the direct outcome, but also how the moral valence of such decisions might affect both their own and other people's view of themselves. As such, moral decision-making is a multidimensional term. Existing research on the relationship between subjective experiences of economic scarcity and human morality appears to be split between two theoretical paradigms, with one predicting mainly negative outcomes on moral judgment and decision-making, and with the other largely arguing for the reverse. Concerning research suggesting negative effects, a selection of studies has found that resource-deprived individuals act greedier 18,26 , are more inclined to engage in dishonest behaviors to obtain resources [27][28][29][30] , exhibit less prosocial intentions 31,32 , and tend to donate less of their personal income to charitable giving 33,34 . These findings may reinforce destructive but prevalent stereotypes and folk beliefs depicting individuals with low SES as irresponsible, dishonest, and "milking the system" . In contrast to this line of literature, other studies have suggested that individuals who subjectively experience economic scarcity are more inclined to emphasize the importance of moral values such as reciprocation, to act in less unethical ways, and to exhibit more prosocial responses 9,20,[36][37][38][39][40][41][42][43] . One of the most prominent studies from this body of research has shown that individuals who perceive themselves as being of lower social class act in a more generous, charitable, helpful, and trusting way compared to those who perceive themselves as being of higher social class 37 . The main theoretical argument behind such findings is that subjective experiences of economic scarcity, in the form of low social class perceptions, are assumed to increase individuals' contextual orientation in their display of moral behavior 36 . That is, individuals who perceive themselves as having lower social class demonstrate an externally-focused cognitive and relational orientation, which enables them to exhibit greater empathy, more compassion, and more prosocial behavior toward their peers 36 , because they know that their social relationships can aid them in achieving better prospective life outcomes 44 . Several findings have supported these results by showing that individuals with lower incomes elicit greater prosociality, especially toward peers in the same situation 40 , as manifested through more altruistic actions 37 and a greater proportion of income donated to charity compared to higherincome individuals 45 . However, other studies have not been able to replicate the positive relationship between subjective experiences of economic scarcity-in terms of low social class perceptions-and prosociality 31,46 . Some studies also suggest that there is a large degree of country-level variability in this relationship 31 , indicating that the effects of subjective experiences of economic scarcity on prosociality might be highly context dependent, consistent with the notion that macro-level economic inequality might be an important moderator for this relationship 6,47,48 . Lastly, and of particular importance for the current investigation, prior studies have limitations related to cross-cultural generalizability, statistical conclusion validity, and measurement validity. First, most extant studies have limited generalizability as they have predominantly relied on data from a single country-the United Statesdespite indications in past research of potential contextual sensitivity by variations in time, culture, or location [49][50][51][52] . Contextual sensitivity might thus explain part of the inconsistencies in the literature 26,31 . Still, no prior study has implemented a cross-national research design to conduct a systematic, large-scale test of the relationship between subjective experiences of economic scarcity and morality. Second, statistical conclusion validity is also limited in the literature as many extant studies rely on underpowered laboratory experiments [53][54][55][56][57][58] . This is important as studies have found both replicability problems in the form of null-findings and results that are in the opposite direction of those reported in the original research 46 . Third, extant studies on the relationship between subjective experiences of economic scarcity and morality typically focus on a single measure of moral decision-making . Yet, moral decision-making is a multidimensional construct that may include both perceptions of moral identity and character, moral values, prosocial intentions to benefit others, and moral circle defined as the boundary we draw around individuals who we think deserve moral consideration 59 . By studying only one or a few indicators of moral decision-making in isolation, studies decrease measurement validity and have a higher risk of not detecting if subjective experiences of economic scarcity affect some types of morality but crowds out other types. To address the mixed findings and to increase cross-cultural generalizability, statistical conclusion validity, and measurement validity in the literature, we conduct a comprehensive pre-registered test of the relationship between subjective experiences of economic scarcity and measures linked to moral judgment and decision-making. We rely on an extensive and partly representative cross-national survey . This research design provides an opportunity to achieve four important main objectives. Specifically, this research design maximizes cross-cultural generalizability in comparison to previous studies, which have typically been restricted to data from a single country; increases statistical conclusion validity by ensuring a statistically well-powered test of the relationship between morality and perceptions of economic scarcity as indexed by low subjective SES at the individual level and income inequality at the national level; and allows us to examine whether the level of economic inequality at the national level moderates the relationship between subjective SES and morality, while also increasing measurement validity by including four measures associated with morality. Regarding the measurement of morality, we expand previous research by using four measures associated with different aspects of moral decision-making that are considered essential to human morality. These are Moral Identity, which measures how important and central moral issues are to a person's self-concept 60 ; Morality-as-Cooperation, which concerns the moral valence of seven cooperative behaviors considered to be "morally good" across cultures and thus measures the individual's judgment of the importance of these behaviors 21 ; the size of an individual's Moral Circle, which indicates the self-reported number of individuals and entities in the world considered to be worthy of moral consideration 61 ; and Prosocial Intentions to Benefit Others, which captures the amount of monetary resources an individual reports being willing to donate to a national and international charity if given a daily median income in one's respective country 62,63 . In sum, instead of examining only one aspect of moral decision-making, we expand previous research by investigating how subjective experiences of economic scarcity might influence multiple fundamental measures associated with morality, thereby increasing measurement validity and providing more opportunities to compare patterns of findings across indicators within the same study. For our main independent variables on subjective experiences of economic scarcity, we use the MacArthur socioeconomic ladder scale to measure subjective SES at the individual level; and GINI coefficients from the World Bank 64 at the national level as an indirect measure of macro-level differences in perceptions of subjective economic scarcity. For the MacArthur scale, individuals are asked to place themselves on a ladder with 11 steps, where selecting the lowest step indicates that you would place yourself among the people with the least financial resources, least education, and least attractive jobs in your respective country, while placing yourself on the top of the ladder indicates that you place yourself among the people with the most financial resources, best education, and most attractive jobs. Hence, this measure is subjective and oriented toward differences in the perception of scarcity compared to more objective individual-level measures that are rather oriented toward the potential material sources of scarcity. This distinction is important as prior research has found that subjective experiences of scarcity can shift cognitive attention and alter decisionmaking strategies more than extreme, absolute scarcity 3,[10][11][12] . The MacArthur scale has exhibited strong construct validity 65 and strong predictive validity regarding outcomes that are often associated with experiencing economic scarcity, such as lower health status 66,67 and lower subjective well-being 68 . Moreover, recent work has provided evidence suggesting that a reason for the scale's high predictive validity in such domains is its ability to measure two central constructs: economic circumstances and social class 69 . Therefore, we rely on the MacArthur measure of subjective SES to map individual-level perceptions of economic scarcity to gain a more nuanced understanding of the link between subjective experiences of scarcity and morality. With respect to our use of the GINI Index as our national-level indicator of subjective experiences of economic scarcity, this measure is an indicator of the dispersion of financial resources among individuals in a specific economy. It ranges from 0 to 100, where 0 indicates that every single individual in the respective economy has the same income, while 100 indicates that one and only one person earns the entire income. Although the GINI is an objective national-level measure of dispersion of financial resources, in the current investigation we build on prior work arguing that economic inequality can elicit perceptions of economic scarcity 6,[70][71][72][73] and thus conceptualize this measure as a macro-level indicator that indirectly probes differences in subjective experiences of economic scarcity 74 . Prior research has found that higher income inequality increases social comparison in a given context 75 , which can exacerbate social class divisions by saliently outlining one's standing on the "social ladder" 70 . In turn, this breeds competition for resources 72 , increases risk-taking 76 , heightens anxiety associated with status striving 77 , and probes perceptions of relative deprivation 71 , thereby explaining why income inequality has been discussed as an important factor linked to psychological differences in perceptions of economic scarcity 6,76,78,79 . Accordingly, in the current investigation, the GINI index is used as a macro-level indicator of the magnitude of exposure to salient differences in income, thereby indirectly probing differences in subjective experiences of economic scarcity 74 . Because the GINI here indexes subjective experiences of scarcityas triggered by objective wealth discrepancies-it is a more indirect indicator than our individual level SES measure, which is directly focused on subjective experiences of economic scarcity. Some individuals across our studied 67 countries might not be considered to live in actual economic scarcity as indexed by objective measures , and prior meta-analytic estimates only indicate a moderate association between subjective and objective measures of SES 68 . Nevertheless, the use of subjective experiences of economic scarcity allows us to examine how individuals who perceive themselves as "having too little" 4 respond on essential indicators of human morality. In this work, we show, across 67 countries, that individual experiences of economic scarcity in the form of low subjective SES are associated with higher self-reported levels of Morality-as-Cooperation as well as Prosocial Intentions in the form of hypothetical donations toward national and international charities. Moreover, utilizing the GINI coefficient as a crude measure of macro-level experiences of economic scarcity, we show that this relationship, at least in part, holds even at the national level, such that individuals living in countries with high economic inequality, and thus a greater degree of experiences of economic scarcity, report a stronger Moral Identity and a greater Moral Circle. Our research highlights that individual and macro-level experiences of economic scarcity are associated with multiple dimensions of self-reported human morality. --- Results We begin by analyzing the relationship between subjective experiences of economic scarcity and moral judgment using multi-level modeling, both at the individual level and at the country level , while also testing whether there might be any country-level differences in the individual-level relationship. Table 1 reports full models for our four dependent measures, for all 67 countries and for countries where samples were nationally representative with respect to age and gender . We report standardized Fig. 1 | World map of ICSMP survey. The map highlights the countries and regions where data were collected for the ICSMP Survey 62,63 . Sample sizes are scaled to color. Gray areas identify areas where it was not possible to obtain samples. β-coefficients allowing for a direct comparison of the effect sizes and model fit statistics. Sample sizes for each model are reported, given that these varied slightly due to some participants being able to refrain from replying to certain measures in the survey . As a robustness check, we also run our models with imputed data where the missing values are estimated using non-parametric randomforest estimations. The results remain robust to this imputation of data and are depicted in Supplementary Table S4. --- Individual-level economic scarcity and self-reported morality As illustrated in Table 1, after controlling for age and gender, lower individual-level subjective SES predicts higher Moral Identity = -5.54, p < 0.001, β = -0.14, 95% CI [-0.15, -0.13]), higher Morality-as-Cooperation = -0.36, p < 0.001, β = -0.07, 95% CI [-0.08, -0.06]), higher Prosocial Intentions to donate to national and international charities = -2.57, p = 0.010, β = -0.08, 95% CI [-0.09, -0.07]), and a larger Moral Circle, although this latter association is negligible = 1.09, p = 0.003, β = 0.01, 95% CI [0.00, 0.02]). These associations are robust in cross-validations with supervised machine learning algorithms . Replicating our analysis with only the 28 nationally representative samples yields comparable results, although the associations become slightly stronger . Visualizations of these results are shown in Fig. 2 and a country-level summary of the direction of the regression slopes for all 67 countries and for the 28 nationally representative samples, respectively, appears in Table 2 . --- Macro-level economic scarcity and self-reported morality Consistent with the individual-level results, as seen in Table 1, higher degrees of country-level economic inequality predicts higher individual-level Moral Identity = 2.98, p = 0.003, β = 0.13, 95% CI [0.04, 0.21]), and a greater Moral Circle = 2.94, p = 0.003, β = 0.08, 95% CI [0.03, 0.13]). This type of country-level economic inequality, however, is not statistically significantly associated with individual-level differences in Morality-as-Cooperation = 1.53, p = 0.479, β = 0.03, 95% CI [-0.05, 0.10]) or Prosocial Intentions = 1.78, p = 0.118; β = 0.06, 95% CI [-0.02, 0.11]), as is the case with subjective SES. Hence, these results indicate that individuals living in contexts of greater economic inequality attribute greater importance in both symbolizing and internalizing a moral identity , as well as reporting a larger moral circle. Visualizations of these associations are illustrated in Fig. 3 . Supporting the notion that the GINI index could be used as an indirect macro-level measure of perceptions of economic scarcity, we find that our measure of subjective SES is significantly associated with higher inequality as indexed by GINI = -14.79, p < .001, r = -0.07, 95% CI [-0.08, -0.06]) and that the lower quantile of our individual-level measure of subjective SES significantly predicts higher inequality = 11.02, p < 0.001, β = 0.13, 95% CI [0.11, 0.15]). Although the correlations are not strong, the findings are consistent with the argument in prior research that contexts with higher wealth inequality make people engage more in social comparisons with individuals with greater resources and therefore decreases subjective SES 72,75 . Importantly, however, economic inequality does not meaningfully moderate the effect of low subjective SES on any of our indicators of morality . Thus, we do not find evidence that individual differences in subjective SES predict any of our measures of morality differently in more economically unequal countries compared to more economically equal countries. Instead, our results indicate that low subjective SES might have parallel effects with national level income GINI measures of inequality on morality. --- Within-and between country associations Variance partition coefficients 80 for the models indicated that most of the variance could be attributed to the individual level with variance at the country-level ranging from 4.4% at the lowest to 12.3% at the highest . We assume that some of this lack of country-level variance is due to common-method variance inflating the estimates at the individual level 81,82 . Additionally, this lack of country-level variance indicates that the relationship between relative economic scarcity, both on the individual level and country level, and moral character and intentions might be fairly robust across different cultural contexts. The cross-cultural robustness of these relationships also aligns with recent findings using the same data to investigate differences in donation responses, in-group favoritism, and age across the 67 countries 83 . Still, these results do not allow us to identify whether the overall associations delineated in Table 1 exist because within countries, individuals with higher levels of subjective SES tend to score lower on our four dependent measures; or because countries with higher mean subjective SES contain individuals with lower scores on our four dependent measures; or a combination of these potential explanations. Next, we therefore decomposed the associations between our individual-level measure of relative economic scarcity, subjective SES, and our four main dependent measures into their within-country and between-country components following the method proposed by ref. 84. Here, we found that the within-country component of subjective SES was negatively associated with Moral Identity = -29.98, p < .001, β = -0.13, 95% CI [-0.14, -0.12]), Moralityas-Cooperation = -14.63, p < 0.001, β = -0.07, 95% CI [-0.07, -0.06]), and Prosocial Intentions = -18.03, p < 0.001, β = -0.08, 95% CI [-0.09, -0.07]), while the between-country component had no significant predictive power in any of these relationships . Overall, these findings support the interpretation that within the 67 countries, individuals with lower subjective SES report higher levels of Moral Identity, Morality-as-Cooperation, and Prosocial Intentions, respectively. Yet, for the measure of Moral Circle, we found that the within-country component of subjective SES was associated with a larger Moral Circle = 3.06, p = 0.002, β = 0.01, 95% CI [0.00, 0.02]), but that the between-country component was significantly associated with a smaller Moral Circle = -2.89, p = 0.004, β = -0.07, 95% CI [-0.13, -0.02]). Thus, our results suggest a complicated relationship wherein individuals with lower subjective SES report to have a slightly smaller Moral Circle within countries, but primarily that countries with higher mean subjective SES contain individuals who report to have a smaller Moral Circle . This finding implies that the relationship between subjective economic scarcity and Moral Circle is more sensitive to contextual factors. --- Contextual differences In further support of the above interpretation, when exploring the relationship between our measures of morality and the individual-level measure of subjective economic scarcity on the country and region level, the directions of the effects generally remain stable. Still, when running country-level Nested OLS models for all dependent variables, notable differences in effect sizes emerge . For instance, when comparing country-level associations between subjective SES and Prosocial Intentions, the associations were stronger in countries such as India = -6.56, p < .001, β = -0.26, 95% CI [-0.33, -0.18]) and South Africa = -2.77, p = 0.006, β = -0.15, 95% CI [-0.25, -0.04]), while weaker in, for instance, Sweden = -3.00, p = 0.003, β = -0.08, 95% CI [-0.13, -0.03]). Also, region-level clustered correlations indicated that associations between the same variables were larger in world regions such as the Americas = -10.80, p < .001, r = -0.12, 95% CI = [-0.15, -0.10]), while smaller in Europe = -12.01, p < 0.001, r = -0.08, 95% CI = [-0.09, -0.06]). These findings illustrate notable contextual differences between how and when subjective experiences of economic scarcity at the individual level might be associated with moral decisionmaking. --- Robustness checks and results summary Lastly, to add further robustness to our main results, we formulated a set of supplementary models using adjusted disposable net-income as an objectively oriented national-level indicator of experiences of economic scarcity. Here, we show that the associations go in the same direction as the results reported in our main analyses . That is, adjusted disposable net-income is negatively associated with Moral Identity, Morality-as-Cooperation, and Prosocial Intentions, but not significantly related to the size of an individual's Moral Circle. Overall, our results indicate robust associations between individual-level and country-level subjective experiences of economic scarcity and moral judgment. Contrary to existing theoretical paradigms concerning resource scarcity and morality 7,16,18,26,27 as well as our own pre-registered prediction , we find evidence for the notion that subjective experiences of economic scarcity are not associated with a "depletion" of moral character or less prosocial intentions. Instead, it seems that such subjective experiences are associated with a stronger preference for identifying and acting as a moral individual, engaging in cooperative behaviors with a clear moral foundation , and having the intention to engage in prosocial charitable giving. --- Discussion Research investigating how subjective experiences of economic scarcity affects human moral judgment and decision-making has yielded mixed and at times contradictory results. Based on studies showing that scarcity can shift cognitive functioning 11,13,19,[85][86][87] , together with a selection of recent findings highlighting a possible causal link between individual perceptions of relative resource scarcity and unethical or antisocial behavior 20,26,27,88,89 , our pre-registered analysis tested the claim that individuals with lower subjective SES and those living in more economically unequal societies would attribute lower importance to acting as moral individuals in terms of identity, cooperation, and prosocial intentions. We found the exact opposite: Conducting a large cross-cultural investigation of these relationships and relying on a dataset including data from 67 countries, our results showed that within countries, individual differences in subjective SES were negatively associated with Moral Identity , Morality-as-Cooperation as well as Prosocial Intentions in the form of hypothetical donation intentions toward national and international charities . Furthermore, between countries, individual differences in subjective SES were negatively associated with the size of one's Moral Circle . As such, individuals who subjectively experience economic scarcity not only seem more inclined to perceive themselves as moral individuals , but also seek to project such morality-related aspects toward their peers and in-group members . Importantly, we show that this relationship, at least to some extent, holds even at the national level, such that individuals living in countries with high economic inequality , and thus a greater degree of subjective economic scarcity, report a stronger Moral Identity but also a greater Moral Circle . These associations are robust in cross-validations . Yet, how should these findings be interpreted? Previous research has argued that individuals who perceive themselves to be of low social class have an increased contextual social orientation. Hence, the link between subjective experiences of economic scarcity and prosocial intentions could reflect the possibility that individuals with lower subjective SES exhibit more prosocial intentions toward others to aid in generating better future life outcomes . This interpretation aligns with previous research, which has suggested that individuals with lower SES donate a larger proportion of their income to charity 92 . Similarly, recent data from the World Giving Index suggest that countries characterized by high levels of economic inequality and an objectively large number of individuals living below the poverty line tend to score higher on this index with respect to prosocial behaviors, such as helping a stranger in need, volunteering, and donating to charity organizations 93 . The relationship we find between subjective experiences of economic scarcity and Moral Identity suggests that individuals who perceive such scarcity might aim to act more moral, because they are more attentive to their social environment as their life tends to be influenced by forces which they cannot necessarily control . Acting as a moral individual might not be as important if you perceive the world from a more individualistic perspective, which people with subjective higher SES tend to do 36 . The observed relationship between subjective experiences of economic scarcity and Morality-as-Cooperation indicates that the moral valence of cooperation principles receives higher importance in populations where resources are scarce. At a general level, managing external constraints and depending on others require some, albeit differing, degrees of cooperation in order to gain fruitful outcomes 96 . Consequently, morality is considered a central foundation of cooperative behavior 97,98 and one of the main functions of morality is to promote fruitful cooperation 23,24,[96][97][98][99] . The concept of Morality-as-Cooperation rests upon the assumption that certain forms of cooperative behavior, such as helping a family or group member, reciprocating, and sharing resources, are considered morally good across cultures 21,97 . Our results indicate that individuals living with subjective experiences of economic scarcity are more inclined to value whether someone helped a member of their family or worked to unite a community when they decide on whether something is right or wrong 21,97 . Thus, our findings on Morality-as-Cooperation suggest that these individuals are particularly prone to consider their external environment when contemplating on moral decisions, likely because they know that they depend on such cooperative connections to obtain more favorable life outcomes. Regarding the links between subjective experiences of economic scarcity and the size of one's Moral Circle, the magnitude of these associations implies that they should be interpreted with caution. Between countries, we find suggestive evidence that individuals tend to have a slightly smaller moral circle in countries that are characterized by higher average SES, with the same being true for individuals living in more economically unequal societies. However, for subjective SES, it should be stressed that this association is very small and complicated by substantial heterogeneity across societies. Having noted that, these results are in line with previous findings showing that individuals from lower social classes exhibit greater empathic accuracy 100 , which might be reflected in the Moral Circle measure used herein . Nevertheless, considering the vast heterogeneity in this measure, further studies on this specific association are needed to determine the relationship between subjective economic scarcity and the size of one's moral circle. While the results of the present study originate from a large, crosscultural research design including 67 countries and appear highly robust, the magnitude of the reported associations is relatively small, and the general explanatory power of our models is modest by conventional standards. However, psychological and cognitive phenomena related to human morality are expected to be influenced by a plethora of different factors 22,[101][102][103] , which means that small effect sizes are to be expected as long as these phenomena are not examined in controlled lab conditions, but rather in real-world settings [104][105][106][107][108] . Therefore, while the effect sizes from our analysis are small, this does not imply that they lack practical relevance [109][110][111] . Effect sizes that are considered small by arbitrary standards can have a large impact when evaluated over time 101,112 or at scale [113][114][115] . This is particularly true for human psychology, where effects can accumulate over time, thus underscoring the fact that while an effect might be small when measured at a single point in time, it can have large ultimate consequences 101 . Also, psychological processes, especially regarding morality, are characterized by "difficult-to-influence" dependent variables, which emphasize that robust small effects can be theoretically important 117 . For instance, our findings demonstrate that an increase of one standard deviation in subjective SES is associated with a decrease of 8% in donation value toward national and international charities, which might seem trivial when considered at the individual level, but can have large consequences for societal outcomes at the population level 60,101,103,118 . In the same vein, it is worthwhile to note that although the current study expands the current state-of-the-art on how subjective experiences of economic scarcity are associated with moral decision-making by studying four well-validated measures linked to morality, other measures might have been relevant to include as well. Therefore, it should be stressed that the current investigation does not aim to conclude whether low subjective SES makes people more or less moral in general. Instead, the present study outlines that certain types of morality seem to be more pronounced under subjective experiences of economic scarcity, speculatively because such morality could aid in producing more fruitful prospective outcomes for individuals subjectively experiencing to be living with less resources. Thus, we do not support a consequentialist view but rather recognize that other types of morality measures might be more pronounced in individuals with more abundant resources, depending on the precise context and the specific type of morality measures used. Relatedly, our individual-level and macro-level measures of subjective experiences of scarcity map how subjective, and not objective, experiences of economic scarcity are associated with our four indicators of moral judgment. Therefore, the current work only outlines how perceptions of "having less" are associated with moral judgment, which naturally comes with both limitations and strengths: Limitations in the form of lacking individual-level objective measures of economic scarcity , but strengths in the form of focusing directly on the subjective experience of economic scarcity, which can hold irrespective of the economic development of a given society. We urge scholars to build on these findings and further investigate how subjective experiences, as well as objective indicators of resource scarcity, might be intertwined and are potentially differentially associated with moral judgment and decision-making. Regarding the macro-level measure of income inequality used as a proxy for perceptions of economic scarcity , it should be noted that this measure constitutes a crude indirect measure of country-level perceptions in economic scarcity. That is, while prior work has shown that higher economic inequality increases competition 72 , social comparison 75 , and a sense of relative deprivation 71 -factors that are all strongly associated with subjective perceptions of economic scarcity 7,119 -it is crucial to note that using the GINI index to capture such perceptions has its limitations. For example, the GINI index cannot directly measure subjective perceptions of economic inequality and is only a single-parameter measure of the distribution of financial resources in a given economy, meaning that it cannot necessarily highlight at what part of the income distribution said inequality is concentrated 120 . Therefore, future work should also assess how individuals in different contexts and across societies directly experience economic scarcity as a result of economic inequality 74 . At the macro-level, using the two-parameter Ortegamodel 120 to distinguish between inequality concentrated at the bottom-and top-income percentiles, respectively, could provide a more detailed perspective on this issue and may spur more fine-grained investigations on how psychological differences in the experience of economic inequality might affect judgment and decision-making within but also beyond the morality domain. Moreover, it is important to acknowledge that the results reported herein rely on self-reported responses. This is a central limitation of the current investigation, as it is debatable whether these measures are capable of capturing responses on metrics such as real, observable behavior. However, previous research has found that self-reported donation intentions are highly correlated with real donations 54 and that self-reported unethical behavior correlates with real-life lying 121 , suggesting that self-report responses are at least somewhat predictive of unethical behavior. For example, our self-reported measure of subjective SES could possibly be influenced by personality differences. However, previous work has indicated strong support for the construct validity of the MacArthur scale 65 and the scale has been used extensively to study how subjective indicators of SES are predictive of outcomes related to subjective well-being 68 as well as physical and mental health 122 . Therefore, considering the robust associations documented herein and the 67 societies involved, our findings contribute to the literature on human morality but should be complemented with future field-based investigations to counter concerns linked to external and ecological validity 105,[123][124][125] . Still, we welcome future research to examine our obtained associations in more realistic environments, preferably using behavioral measures, experimental approaches, and a larger range of control variables to allow for causal inferences. A final note of caution pertains to the fact that the data used in the present investigation were collected during the COVID-19 pandemic. While the general idea regarding the pandemic seems to be that "COVID-19 does not discriminate," recent studies have shown that vulnerable individuals, such as those living with less economic resources, have higher mortality rates than their less vulnerable counterparts 126,127 . The results of the current study not only show a general link between subjective experiences of economic scarcity and human moral judgment, but also suggest that this association is present when people who perceive themselves to have the least resources experience an extraordinary increase in the level of risk and exposure to threat. As research has argued that hostile environments motivate people with less available resources to engage in prosocial behavior 37,128 , our findings may therefore be stronger than similar investigations conducted during pre-or post-pandemic times or data collected in the absence of other public crises 129 . In conclusion, the present research demonstrates that subjective SES and income inequality are associated with multiple dimensions of human morality. These findings underline the complex relationships between social class perceptions and inequalities, and the way individuals morally think, respond, and act. We urge future research to disentangle how moral character and behavior might be associated with not only subjective but also objective experiences of economic scarcity. --- Methods The study was pre-registered on AsPredicted before the data was accessed . While we generally adhered to the pre-registered analysis plan, some deviations still exist. Specifically, for our main analysis, we employed multilevel correlation analysis, nested OLS regressions, multi-level modeling , and cross-validations instead of standard Pearson's correlations and non-nested OLS regressions, thus addressing the same questions as pre-registered but with more sophisticated and robust methods. We have not reported the originally planned analysis in the Supplementary Information as this analysis plan is flawed because it does not account for the inherent clustering in the data in terms of countries. All statistical tests reported are two-tailed and the alpha-level is set at 0.05. Furthermore, our pre-registration noted that we would include household income on the individual level in all of our models. However, this was not possible given that the dataset from the ICSMP project did not include such data 62,63 . That is, because we only had access to the Danish sample in the preregistration stage, we assumed that the data from all 67 countries would include this household income, which was not the case. Nevertheless, to add further robustness to our results, we augmented our data with a measure of Adjusted Disposable Net-Income from the World Bank . The data were obtained from the International Collaboration on Social & Moral Psychology of COVID-19 62,63 . This project was a large-scale international collaboration between more than 200 researchers from 67 different countries with a goal to create an online survey to measure psychological factors underlying the attitudes and behavioral intentions related to COVID-19. The project received ethical approval from the institutional review board at the University of Kent and informed consent was obtained from all participants prior to their voluntary participation in the study. No additional ethics approval was needed for the research reported in this paper. The dataset contains self-reported demographics and social and moral psychology data from 51,089 individuals from 67 countries and 5 different regions of the world. Each national team responsible of collecting data in their country translated the English survey into their nations' language using the standard forward-backward translation method. Members of every participating country were asked to collect data from at least 500 participants, nationally representative with respect to gender and age. No statistical method was used to predetermine the sample size, considering that the estimated final sample of several thousand participants would have sufficient statistical power to detect very small effect sizes by conventional standards. The data were collected from online platforms or panel agencies during April-May 2020 and were administered using an online survey. Every participating individual answered questions regarding demographics and self-reported public health behaviors as well as a series of psychological measures. Scale order was randomized for every participant. The dataset was cleaned by the lead methodologists from the ICSMP project for the initial publications using the dataset 62,63 . A total of 53,269 participants answered the survey. Of these, 2049 participants were excluded for not having completed the full survey, and 131 participants were excluded for being younger than 18 y/o or older than 100 y/o. Furthermore, we removed 526 participants who failed attention checks and 167 individuals reported "Other" as their gender identification. For gender identification, we excluded these participants from our formal analysis to reduce the risk that this category of the covariate would inflate the results obtained from our models, given that the "Other" category was too infrequently represented in the data for meaningful country comparisons. That is, to maintain a balanced representation of the gender covariate in the dataset, the small number of participants identifying as "Other" were excluded, ensuring robust estimation and interpretation of regression coefficients related to gender. This resulted in a final sample of 50,396 participants. Of the 67 countries, 28 countries used fully representative samples with respect to gender and age. Nationally representative samples were collected using stratified sampling, while non-representative samples were collected using convenience sampling. A total of 44 countries included more than 500 participants. Mean age was 43 years and 52% of participants reported their gender as female. In addition to data from the ICSMP, we obtained the most recent GINI Indexes from the World Bank 64 for every country included in the study, with some rare exceptions. Taiwan GINI data were obtained from Statista 130 , Cuban GINI data were obtained from Reuters 131 and New Zealand and Singapore GINI data were obtained from Knoema 132,133 . Region names were obtained from the World Bank Development Indicators 134 . --- Variables Moral Identity was measured using a scale of 10-items 60 such as "It would make me feel good to be a person who has these characteristics", which would be answered based on a description of a person who has the characteristics: "caring, compassionate, fair, friendly, generous, helpful, hardworking, honest, kind". Each item was measured using a 10-point slider with three labels: 0 = "Strongly disagree", 5 = "Neither agree nor disagree", 10 = "Strongly agree". Items 3 and 4 were reverse scored. Results were aggregated into a single-scale , instead of two subscales , as in the original publication developing the scale 60 . Hence, our aggregated measure of moral identity indicates how important moral identity is to one's self-definition and to what degree an individual expresses this moral identity but does not distinguish between these two aspects. To investigate and validate the equivalence of the factor structure of this scale across societies, we carried out Multiple-Group Factor Analysis Alignment as proposed by ref. 135. In this analysis, results showed that for factor loadings the scale exhibited 8.5% of non-invariance for item parameters and 7.8% for intercepts, which indicates that the majority of non-invariance is absorbed by our country-varying factor means and variances. Hence, following ref. 135 suggestions of a cut-off value of 25% in order to consider a scale non-invariant, we deemed the scale suitable for use in the current investigation, consistent with recent projects who have used the data and the specific scales 136 . The full results of the Multiple-Group Factor Analysis Alignment for Moral Identity can be found in Supplementary Tables S16-S21. Morality-as-Cooperation was measured using a 7-item scale adapted from ref. 25. Each item represented one question out of three from each of the seven "relevance items" from the Morality-as-Cooperation questionnaire 25 . The questions chosen from the original scale were the ones with the highest predictive validity 62 . Individuals were initially asked the following: "When you decide whether something is right or wrong, to what extent are following considerations relevant to your thinking?". Here, the "family" item was labeled "Whether or not someone helped a member of their family". The "group" item was labeled "Whether or not someone worked to unite a community". The "reciprocity" item was labeled "Whether or not someone showed courage in the face of adversity". The "deference" item was labeled "Whether or not someone deferred to those in authority". The "fairness" item was labeled "Whether or not someone kept the best part for themselves". The "property" item was labeled "Whether or not someone kept something that didn't belong to them." Each item was measured using a 10-point slider with three labels: 0 = "Strongly disagree", 5 = "Neither agree nor disagree", 10 = "Strongly agree". All 7 items were aggregated into our single measure of Morality-as-Cooperation . In the original publication developing the scale, test-retest correlations for the full scale was shown to range from 0.79 to 0.89 25 . Again, to investigate and validate the equivalence of the factor structure of the scale across societies, we carried out Multiple-Group Factor Analysis Alignment. Here, the results showed that for factor loadings the scale exhibited 10.4% of non-invariance for item parameters and 14.1% for intercepts, which, as for Moral Identity, indicated that the majority of noninvariance was absorbed by our country-varying factor means and variances. Based on the same argumentation as for the Moral Identity scale, we therefore deemed the factor structure of this scale sufficient for use in the analyses reported in this paper, in line with previous investigations that have used this scale in a multi-national context across 60 countries 21 . The full results of the Multiple-Group Factor Analysis Alignment for Morality-as-Cooperation can be found in Supplementary Tables S22-S27. Moral Circle was measured using a single-item scale with 16 levels 137 , asking participants to indicate the extent of their moral circle, where moral circle means "the circle of people or other entities for which you are concerned about right and wrong done toward them." The scale ranges from 1 = "all of your immediate family" to 16 = "all things in existence". Test-retest reliability of the scale has previously been shown to be .61 138 and the scale has been validated and used in numerous previous investigations across different disciplines . Prosocial intentions were measured using a hypothetical choice task with three items. In this task, individuals were asked how much , if given a daily median income, they would be willing to 1) keep to themselves, 2) donate to a national charity and 3) donate to an international charity. We formed our measure of prosocial intentions by aggregating the second and third item across individuals. Subjective socioeconomic status was measured using the single-item MacArthur ladder scale 138 . This scale uses a picture of an 11step ladder and asks participants where, in their country, they would stand if the top indicated the people who are the best off-those who have the most money, the most education, and the most respected jobs, while the bottom are the people who are the worst off-those who have the least money, least education, and the least respected jobs or no jobs. Participants indicated their standing in their respective society from 0 to 10 . The scale has been used extensively in previous research to capture subjective social class across disciplines . GINI Index, as measured by the World Bank, is based on primary household survey data obtained from statistical agencies and World Bank country departments 64 . It measures the amount of income inequality, where 0 = total equality and 100 = total inequality. For more information on specific measurement and methodology, see PovcalNet from the World Bank . --- Correlations Due to the nested structure of our data, the correlations between the variables; Subjective Socioeconomic Status 138 , Moral Identity 60 , Morality-as-Cooperation 25 , Moral Circle 137 , and Prosocial Intentions were calculated using multilevel Pearson's correlations with country as the random intercept. We also calculated grouped correlation coefficients for every country and region in the dataset to identify countrylevel and region-level differences of interest . Correlations between our dependent variables and the independent variable "GINI Index" were calculated as single-level Pearson correlations without the multilevel nesting, as the GINI Index would not be different per individual measure, as it constitutes a country-level measure. Lastly, for exploratory purposes, we also calculated a simple correlation between the dependent measures of Moral Identity, Morality-as-Cooperation, Moral Circle, and Prosocial Intentions , which can be found in Supplementary Tables S2-S3. --- Multilevel models To probe the internal validity and contextual sensitivity of our results, we rely on advanced statistical methods in the form of multi-level modeling and cross-validations using supervised machine learning algorithms. These methodological approaches allow us to identify robust individual and country-level associations between subjective experiences of economic scarcity and morality. In doing so, we contribute with a rigorous cross-cultural and generalizable extension of previous research 20,37,38,46,49,90,142 on how our studied facets of economic scarcity might affect moral judgment and decision-making. To test the robustness of our results, we also include adjusted disposable netincome in each included country as a more objectively oriented national-level indicator of experiences of economic scarcity in a set of supplementary models . We performed three specific forms of multi-level modeling. Firstly, we performed linear mixed effects modeling 143 , where we regressed our dependent variables with our two main independent variables and covariates, while using country as the random intercept. Two-tailed significance testing was applied for all analyses. For ease of reporting and interpretation, we standardized parameters to report β-coefficients and 95% confidence-intervals of our analysis. 95% Confidence Intervals and p-values were computed using the Wald approximation. These models use the Restricted Maximum Likelihood algorithm. In this setup, our models use pairwise deletion of missing values before the maximum likelihood estimation. To add robustness to our results, we ran a set of identical models, where we imputed missing data based on a Random Forest estimation. Our results appear robust to this change in the data structure . Secondly, we performed linear mixed effects modeling 143 , this time focusing on the independent variable of subjective socioeconomic status , where we decomposed our associations into within-country and between-country effects 84 . To do this, we formed three new variables from our original measure of subjective socioeconomic status; 1) a grand-mean centered measure of SES, that subtracts the grand mean from each individual observation, 2) a withincountry centered measure of SES which captures variations relative to each country's average by subtracting the raw observation from the country-specific mean, 3) a between-country centered measure of SES which reflects between-country differences in SES, obtained by subtracting within-country centered values from the grand mean centered values. Using these new variables, we formulated a selection of models where we regressed our dependent variables on morality with our new within-country and between-country measures of socioeconomic status, GINI Index, covariates, and country as the random intercept. Again, to add robustness to our results, we ran a set of identical models, where we imputed missing data based on a Random Forest estimation. Thirdly, we performed Nested Ordinary Least Squares regressions on all dependent variables, with SES as the independent variable, as only this variable would differ at the individual level, given that GINI is a country-level measure. Country was used as nesting, such that we simultaneously ran 67 OLS regressions for each of our dependent variables. This approach allowed us to identity the individual country-level coefficients for each of our models. Full results of these models are reported in Supplementary Tables S11, S12, S13, S14, and visualizations are reported in Supplementary Figs. S3, S4, S5, S6. --- Cross validations As a robustness check to assess the predictive power of our models, we applied 10-fold cross validation, with 200 repetitions on all multilevel models. Cross-validation is a form of supervised machine learning which splits the dataset into K number of independent datasets and then uses every dataset in turn as the validation set, where the other K-1 datasets then act as the calibration sets. Each fold of the data leads to a different estimate of the Root Mean Square Error of the model and therefore the process is repeated multiple times to get reliable estimates. While cross-validation can be used as a procedure in model selection, in this article we used the procedure to validate the robustness of our models 144 . That is, our cross validations provide confidence in the reported findings, by illustrating that the included model results are in fact the ones with the lowest RMSE. The full results of all cross validations can be found in Supplementary Table S15. --- Reporting summary Further information on research design is available in the Nature Portfolio Reporting Summary linked to this article. --- Data availability The raw and preprocessed ICSMP data are publicly available at OSF 62,63 . The processed GINI and Adjusted Net-Income data are publicly available at OSF 145 and was obtained from the World Bank 64 . --- Code availability The analysis code was written in the statistical environment R and the script is openly available at OSF 145 . This analysis code can directly reproduce all figures and tables reported in the paper, the Supplementary Data and the Supplementary Information. --- --- Competing interests The authors declare no competing interests. --- Additional information Supplementary information The online version contains supplementary material available at https://doi.org/10.1038/s41467-023-41007-0. Correspondence and requests for materials should be addressed to Christian T. Elbaek. Peer review information Nature Communications thanks the anonymous reviewers for their contribution to the peer review of this work. A peer review file is available. Reprints and permissions information is available at http://www.nature.com/reprints Publisher's note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author and the source, provide a link to the Creative Commons licence, and indicate if changes were made. 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Individuals can experience a lack of economic resources compared to others, which we refer to as subjective experiences of economic scarcity. While such experiences have been shown to shift cognitive focus, attention, and decisionmaking, their association with human morality remains debated. We conduct a comprehensive investigation of the relationship between subjective experiences of economic scarcity, as indexed by low subjective socioeconomic status at the individual level, and income inequality at the national level, and various self-reported measures linked to morality. In a pre-registered study, we analyze data from a large, cross-national survey (N = 50,396 across 67 countries) allowing us to address limitations related to cross-cultural generalizability and measurement validity in prior research. Our findings demonstrate that low subjective socioeconomic status at the individual level, and income inequality at the national level, are associated with higher levels of moral identity, higher morality-as-cooperation, a larger moral circle, and increased prosocial intentions. These results appear robust to several advanced control analyses. Finally, exploratory analyses indicate that observed income inequality at the national level is not a statistically significant moderator of the associations between subjective socioeconomic status and the included measures of morality. These findings have theoretical and practical implications for understanding human morality under experiences of resource scarcity. Subjective experiences of economic scarcity, hereinafter defined as the perceived lack of economic resources as a result of social comparison, are a structural characteristic of modern societies and a persistent cause of concern 1,2 . Such experiences are not necessarily the same as the actual circumstances of having low wealth or low income, and may not always correlate strongly with objective indicators of scarcity 3,4 . Nevertheless, subjective experiences of scarcity are increasingly indexed by low subjective socioeconomic status (SES) at the individual level and income inequality (GINI) at the national level [5][6][7][8][9] . An expanding body of literature has found that subjective experiences of economic scarcity, as well as experiences of other types of resource deprivation like hunger or thirst, can shift human cognition and judgment, changing intentions and subsequent behavior 7,10-15 . Specifically, subjective experiences of economic scarcity have been shown to alter executive functioning and fluid intelligence, increase future discounting, and lead to more impulsive and risk-seeking behavioral manifestations 7,[10][11][12][13][14][16][17][18][19] , while simultaneously decreasing psychological well-being 4 . Yet, the implications of such experiences for

INTRODUCTION Goal setting, in all organizations, is a vital function through which individual goals are transformed into organizational policies and actions . For family firms, these activities are likely to be more complex owing to the unique systemic interactions between the family and the business . A family can use its power and discretion to influence decisions and foster the adoption of familycentered goals . Given that family firms are very common , and given that family-centered goals play an important role in the theory of family firms , it is surprising that only limited attention has thus far been paid to how organizational goals are determined in these organizations . Thus, addressing the issues underlying the goal formulation processes in family firms appears warranted. The family is seen as a dominant group within the family firm . According to Cyert and March , it follows that family-centered goals will become more salient as the family coalition increases its representation and authority within the organization. However, the relationship between family involvement and the adoption of family-centered goals is likely to be complex, and mediated and moderated by several factors . Goal setting involves individuals, groups and firms, nevertheless, the relatively scarce studies available are limited to the firm level, typically relying on single informants and overlooking the individual organizational member's role in the process. In this study, we attempt to broaden and refine the extant theory in the area of organizational goals and goal formulation processes in family firms by addressing the following research question: How do the individual goals of organizational members influence the organizational goals pursued by family firms? Given the ambiguities inherent in multilevel research, qualitative methodologies were considered particularly appropriate to accomplish our purpose . We undertook interviews and gathered non-participant observations and archival documents from 19 family firms; thereafter analyzing these qualitative data to disclose the unexplored dynamics of goal setting in family firms. The evidence presented in this article refines and extends current understanding of how family involvement engenders the adoption of family-centered goals in organizations, and offers new insights on intra-family succession as an ideal occasion for challenging the status quo and fostering the restabilization of new organizational goals. Finally, this study reveals the critical contribution that studying these aspects of goal setting can make to theory building in the area of organizational behavior and stakeholder management, as well as enhancing practical understanding of organizational goals in family firms. The article is organized as it follows: in the next section, we set the foundations for our study by reviewing insights from prior research on goal setting and from family business literature. In the third section, we outline the research design and methods. Thereafter, we present the key findings and the inductive process that led us to formulate our theoretical propositions. Finally, we discuss the implications of our findings and draw conclusions. --- BACKGROUND Organizational goals are an important yet controversial concept in organization theory . In contrast to the economic approach of modeling firm decisions made by unitary actors, organizational theorists challenge the assumption that organizations have simple, well-defined goals and conceive work organizations as political entities in which coalitions are formed among individuals to influence the goals that the firm will pursue . According to this perspective, organizational goals may change over time, reflecting the goal setting processes among coalitions that presumably pursue conflicting and inconsistent goals . Thus, defining the goals adopted by an organization requires specifying who is able to influence firm decisions, the elements that may affect their individual goals and, more importantly, the processes through which the individual preferences are translated into organizational policy and action . Some researchers assume that the relative importance of different goals in an organization is a function of the power of individuals or groups of individuals in decisionmaking processes . The theory of stakeholder salience , for example, suggests that managers pay sequential attention to internal and external stakeholders based on the evaluation of their attributes of power, legitimacy and urgency. However, managers are not necessarily a cohesive group , and thus can only loosely be defined as a coalition. Furthermore, several organizational members can influence firm behavior through their decisions in different organization units , while goal setting processes do not necessarily follow hierarchical arrangements among coalitions . Consequently, in order to avoid implementation gaps, the formulation of organizational goals cannot be limited to the top management team, but should also involve other individuals at different levels of the organization . According to Cyert and March , organizational goals are formed through a process that is articulated in three steps: first, coalitions are formed and coalition goals are defined through internal bargaining and side payments; second, goals are stabilized and elaborated into control-systems that define policy constraints to organizational member actions; finally, organizational goals are continuously updated on experience gained . Research in social psychology and political science provides further insights in this regard, suggesting that individuals purposefully form coalitions to pursue their goals , and that coalitions will tend to be inclusive to increase their bargaining power and maximize policy outcomes for its members . Combining the insights from this body of research with the description of goal setting processes proposed by Cyert and March , Stevenson et al. concluded that the problem of defining organizational goals is closely linked to that of defining coalitions. They suggest that coalitions are continuously formed in organizations in response to variations in organizational resources, creating conflicts among organizational members and subsequent bargaining mechanisms that lead to determining joint actions. A key assumption in this literature stream is that occupational roles are almost completely separate from personal goals . It follows that the examination of goal setting processes is typically abstracted from the individual motives that determine participation, and the nature of the processes is largely limited to the business sphere. These restrictions become problematic when aiming to extend these insights to the family firm context for at least two reasons. First, family members share common bonds and mutual expectations that may generate alternative, less tangible forms of side-payments . Second, relational contracting is juxtaposed to purely economic contracting in family firms , making organizational processes highly ambiguous compared to those of non-family firms. Moreover, family business literature informs that additional complexity in coalition and organizational goal formation lies in the extent of the overlaps between the family, the ownership and the business systems, which presumably can also change over time . Prior studies have shown that providing their families with financial security and other non-economic benefits is often recognized as an important goal of owner-managers in family firms . However, not all family firms pursue family-centered goals and the relationship between family involvement and the organizational goals adopted by family firms is likely to be complex . Although family firms are an interesting context in which to examine goal setting processes and family-centered goals are important in explaining their particularistic behaviors and outcomes , research exploring the antecedents of family-centered goals is scarce. Extant research investigated family firm goals at the firm level, typically relying on a single informant, and thus neglecting the antecedents and processes that characterize goal setting in these firms. As a consequence, understanding and predicting the adoption of family-centered goals by family firms remains an important challenge for the development of a theory of the family firm. New perspectives and innovative research approaches are required to perceive the complexity of goal setting implicit in family involvement in the business, and build a more fitting theory on the adoption of family-centered goals in family firms. --- METHODS Our aim is to build theory in the area of family business organizational goals and to broaden existing theory by extending and refining the categories and relationships that have been left out of the literature . For this purpose, we conducted a theory-building qualitative study to better understand the unexplored dynamics of goal setting in family firms. --- Sample and Context Data were obtained from interviews, non-participant observations and archival documents gathered from small and medium family firms in Italy. We first identified a set of firms that could potentially be included in the study through preliminary interviews with professionals collaborating with the Center for Young and Family Enterprise of the University of Bergamo, which provided a preliminary list and references for 36 family firms from their professional networks of small and medium firms. After establishing contact with the CEOs and conducting preliminary interviews, we selected a subsample of 24 firms that met the following three conditions: ownership majority was held by members belonging to one family, two or more family members were actively involved in the business, and the CEO perceived the firm as a family firm . Among these, 5 CEOs declined participating due to time limitations, while we obtained informed consent from the CEOs of 19 family firms to conduct interviews, to participate as observers in family and business meetings and to access their archives. The 19 family firms included in the final sample were equally distributed between manufacturing and service industries, as well as between industrial and business-to-consumer industries . Firm size ranges between 17 and 206 employees with an average of 66. Firm age ranges between 13 and 206 years since foundation, the average is 31. Seven firms are controlled by the founder generation, eight by the founder's heirs and four firms by descendants up to the sixth generation. Finally, 10 family firms are expecting an intra-family succession to occur within the next 5 years, whereas 9 family firms went through a succession in the five years prior to the study. This sample and context was thought to be sufficiently large and diverse to provide an excellent opportunity to examine goal setting in family firms. First, the choice of focusing on small and medium firms is a reasonable compromise between the degree and nature of goal conflicts most likely to be observed. Although large firms may present greater goal conflict due to the larger number and variety of internal and external parties that are able to make claims and influence the business agenda, in smaller firms such conflicts are more likely to concern familycentered goals. Furthermore, the influence of a controlling family is more strongly felt and the interactions between family and business are more likely to be observable . Thus, our choice implied trading external validity against opportunities to gain valuable insights on the idiosyncratic outcomes engendered by the interplay between family, ownership and business systems. In addition to considerations on firm size, the inclusion of family firms that are well distributed in terms of firm age further extends the possibility of providing valuable insights into goal formulation processes in family firms. This was deemed necessary to capture the differences in terms of within-group alignment of family members, which is acknowledged as differing across family firms at the founding, sibling-partnership and cousin-consortium stages . Furthermore, the segmentation according to the family generation in control was considered important since this has been shown to affect many management processes . Finally, the stage of the succession process was also considered important since, by definition, a succession is a process that implies significant organizational changes, including organizational goals . Once we defined the sample of firms, in order to build and elaborate the theory we searched for a purposeful sample of family business organizational members covering a wide range of membership and role categories. Specifically, to facilitate the theory building, we searched for a context that could serve as an "extreme case" with dynamics that are more visible than in other contexts. In particular, we chose to explore goal differences among different groups of organizational members within a general context, namely, the family firms as defined above. Consistent with the overlapping circles model, which portrays a static degree of interaction between the family and the business , we chose to include in the study members of family firms within the dominant coalitions of the family, ownership and business entity systems. We represent the segmentation of the family firm's organizational members by examining Chief Executive Officers , professional top executives , young generation family members , family CEO spouses and old generation family members . This set of organizational members maximized the differences along four dimensions that were considered particularly relevant to our study. First, we selected individuals that own equity shares of the firm and others that do not, since ownership is likely to affect the incentives and priorities of organizational members . Second, we selected family members as well as non-family members because the latter could be expected to follow a self-serving attitude, whereas family-members are possibly more oriented towards the family firm's collectivistic goals . Third, we selected family members who are actively involved in the business and those who are not, since they may differ in terms of their power in the organization and how they perceive the family and business priorities . Fourth, we selected family members that belong to the current CEO's generation, to the younger generation and to the older generation, since research has pointed to relevant differences between incumbents and descendants . Given these differences among the types of family firms and organizational members, we felt that this combination would provide enough distinct windows through which to view organizational member individual goals. Taken together, this sample and context provide an excellent opportunity to examine goal setting in family firms. Using the purposeful sample of family business organizational members distributed over types of role and involvement, we collected data up to "theoretical saturation". Although guidelines to determine non-probabilistic sample sizes are virtually nonexistent , we stopped when no new information or themes were observed in the data, which resulted in a sample of 76 informants. The distribution of informants across firms and any additional information of the interviewees in the sample are presented in Table 1. Demographically, our sample was approximately 18 percent female, with women quite uniformly distributed among members involved and not involved in the business , family and non-family members , and family generation . Informant age ranged between 25 and 68, the average informant age is 39. --- Insert Table 1 about here --- Data The primary data collection method involved semi-structured interviews with the aforementioned informants. Initially, we obtained preliminary information by asking questions in relation to the family firm and the interviewee . This common set of questions allowed us to observe variations in interviewee responses across different organizational members of the family firm. To address and specify the objectives of our analysis, and to consistently develop the interview questions, we followed a pyramidal algorithm of interview question development . The central research question was therefore articulated into the following theory questions: What goals do family firm organizational members pursue? How do such goals relate to the individual characteristics of the informants? How do these relationships change across family firms? How do the individual goals of family firm organizational members affect the decision making processes in family firms? From each of these theory questions, we developed those to be included in the interview protocol . Interviews lasted between 30 minutes and two hours, and all were conducted onsite subsequent to the informed consent of the participant. The authors recorded the interviews and took notes; all interviews were transcribed verbatim. The utility and reliability of interviews as a form of data collection is subject to scholarly debate, some emphasize the fruitfulness and underutilization of self-reports and firsthand narratives to understand subjective work experiences , while others stress the weaknesses of such approaches by reason of the tendency of informants to adjust their responses to maintain a positive self-image and create favorable impressions . For this reason, we used interviews as our primary source of data but also attempted to offset the limitations of this method by using additional methods where possible. In particular, we continually followed informants during family and business meetings , formulating general observations of how goals form part of everyday family and business life. Access was relatively consistent across cases, with at least three meetings observed in each firm for a total of 114 meetings. These enabled confirming informant descriptions of their organizational roles, assessing the general family business environment and observing the processes through which organizational goals are set as closely as possible. In addition, we gathered archival documents from various sources in all firms, including contracts, historical books about the organization and the family, corporate websites, news articles about the firm and the family, and firm pamphlets. Taken together, these secondary sources of data provided a richer context to understand goal setting in family firms. --- Data Analysis In order to understand the goal formulation processes in family firms, we independently read interviews, observations and archival data, applying open in vivo coding using the qualitative data analysis program NVIVO , which also enabled exchanging memos to capture themes and broad observations. More specifically, we iteratively analyzed the qualitative data by moving back and forth between the data and an emerging structure of theoretical arguments that responded to the theory questions presented above, according to three key steps . The first step consisted in creating provisional categories and first-order codes. For each theory question, we began by identifying statements on our informants' views of the world via open coding , thereafter drawing on common statements, comparable episodes and equivalent content in archival data to form provisional categories and first-order codes. Following Miles and Huberman , we used a contact summary form to record the provisional categories that emerged in each data source at each point in time. At times, the revisited data did not fit well into a category, which led to either abandoning or revising a category. We began by reading all transcripts and generating contact summary sheets following specific disciplines. Once contact summary sheets were completed, we met numerous times to create theoretical categories that could be relevant to answering the theory questions. As theoretical categories were created, we went back and recoded the data to see if the codes fitted the emerging abstractions. Where this was not the case, we reviewed the "discrepant data" and revised the categories accordingly. We continued this process until both reviewers agreed. The second step consisted in integrating first-order codes and creating second-order themes. Codes were consolidated for each group, namely, we summarized the contact forms compiled from all the data collected from CEOs, PMs, YGs, CSs and OGs into different sets of themes, from firms at different generations of family control and at different stages of the succession process. This stage of analysis allowed us to make a comparison across roles and identify differences within and across different types of family firms as well as changes in our variables of interest . As we consolidated the categories, they became more theoretical and abstract, and we hence moved from open to axial coding . By way of illustrating, to answer the first theory question we started by coding statements that differentiated between right and wrong goals for the family firm, which led us to observe that organizational members attribute different connotations to identical goals. We used the theme "goal meaning" to capture these elements. The third step involved delimiting the theory by aggregating theoretical dimensions. Once second-order themes had been generated for each theory question, we sought to aggregate the dimensions underlying these themes in an attempt to understand how different themes fitted into a coherent picture. We brainstormed alternative conceptual frameworks or models that described how these themes relate to each other and to available organizational theories. Once a possible framework was identified, we reexamined the data's fit/misfit with our emergent theoretical understanding . Figure 1 summarizes the process that we followed, showing our first-order codes, second-order themes and aggregate theoretical dimensions for each theory question. Specifically, the aggregate theoretical dimensions shown were the ones that best explained the goals pursued by family firm organizational members and the processes through which organizational goals were formulated. Insert Figure 1 about here --- FINDINGS As we looked at the data from each family firm, three main findings became apparent. First, organizational members within a family firm have manifold individual goals that concur with the emergence of goal diversity, which is also affected by firm-level factors such that goal diversity appears to be more pronounced when an intra-family succession is imminent. Second, goal diversity triggers the social interaction processes through which organizational members contrast their goals in an attempt to restabilize the conflict. In particular, two different types of social interaction processes were identified based on significant differences in terms of setting, norms and means of bargaining and stabilization. Third, familial social interactions appear to be more effective than professional social interactions in managing goal diversity in family firms and generating collective commitment to family-centered goals among organizational members. In describing this process, we begin with a discussion of the goals pursued by organizational members in family firms, which helps inform on the individual-level antecedents of goal setting in family firms and, ultimately, on how goal diversity and goal conflicts arise therein. We continue by presenting the social interaction processes through which goal diversity is managed as well as their implications for organizational member commitment to familycentered goals. We conclude this section by proposing a theoretical model that integrates the findings of this study and builds new theory in the area of goal setting in family firms. --- Behavioral Relevance of Goal Categories: The Emergence of Goal Diversity A taxonomy of organizational member individual goals in four goal categories emerged from the iterative comparison of the empirical evidence and previous literature, and this contributed to answering our first theory question on the goals pursued by family firm organizational members. --- Insert Table 2 about here The taxonomy, summarized in Table 2, is formed along the two dimensions of goal content and goal recipient . The first goal category is family centered economic goals , typically emphasized by family members committed to keeping company control in the hands of the family and to generate various forms of wealth for the family: I made the company what it is now, and I want to see our family continue running the business through their own efforts I come from a modest family, my first goal was, and still, is to improve our lives. One could say, what we do is to ensure a future for our children. A second category of goals were again oriented to benefit the family but were noneconomic in nature. In the family centered non-economic goals category, we included mentions of goals such as preserving harmony within the family, promoting family social status and reputation, and maintaining a link between the family and the business identity: I feel that maintaining a good atmosphere in the family is one of the most important drivers of the behavior of our company. We want to be recognized as an engine of our territory's economic development. --- The long lasting values of our family must be a guiding reference for our future actions. The third category of goals was not explicitly oriented to the family and was strictly related to the economic aspects of business. These non-family centered economic goals included disparate indicators of economic performance such as growth, survival and profit: Increasing the value of our assets as well as the expectations of value-creation in the future are considered imperatives. Ultimately, it is important to establish actions aimed at preserving the market position that we have achieved up to now. First of all, we must aspire to keeping the business alive. Finally, non-family centered non-economic goals were goals intended to satisfy other stakeholders than the family and were not related to economic aspects. These goals embraced the improvement and conservation of good relationships with internal and external stakeholders, such as employees and the external community: I feel a strong responsibility towards our employees and their families. We should keep in mind that we are part of a community that gives us a lot…We want to reciprocate with our activities. I think that the actions of our company must satisfy ethical requirements, without cheating or shortcuts. While discussing these goals, the organizational members involved in the study expressed several opinions and judgments including comments in relation to their meaning and their importance. We conveyed these instances into the theoretical dimension behavioral relevance of goals. Each organizational member discussed multiple goals belonging to different categories and each organizational member was also able to identify a subjective hierarchy among these goals, which allowed us to define the goal category that is most relevant to each informant. Comparative analyses of the behavioral relevance of goals by informant characteristics revealed a number of notable insights on how the relative relevance of the different goal categories relates to individual membership within the family, ownership and business systems, and to the characteristics of the family firm1 . To briefly present the key insights derived from this body of evidence, we summarize our findings on the determinants of organizational member individual goals into three general observations. These observations answer our theory questions in terms of individual goals and how these goals relate to the characteristics of the informants and firms. They contextualize and reinforce existing understanding of family firms as a result of unique systemic conditions engendered by the interaction of the family unit, the business entity and individual family members . This implicitly incorporates the idea that systemic interactions in family firms can lead to the coexistence of manifold individual goals contributing to the formation of organizational goals. In addition, these observations serve to introduce the individual-level antecedents of goal setting in family firms for the purpose of examining how individuals influence organizational goals in family firms: Observation 1: Organizational member goals in the family firm reflect their membership in the family, ownership and business systems. Observation 2: The individual goals associated with a given configuration of organizational membership vary across firms at different generations of family control. Observation 3: The individual goals associated with a given configuration of organizational membership vary across firms at different stages of intra-family succession. Overall, these initial observations on organizational member individual goals call into question the implicit assumptions in family business research that controlling families share common aspirations and values, and that family involvement can thus be considered a homogeneous dimension that consistently predicts the extent to which the dominant coalition in the firm is likely to pursue family-centered goals . A more nuanced portrait of family member goals emerged from our empirical evidence suggesting that family members embrace a much wider spectrum of individual goals than previously assumed, which provides some support to the contention that goal alignment among family members is not a realistic expectation . Based on this initial body of empirical evidence, we argue that the interactions between the family, ownership and business systems generate goal diversity within a family firm, and that such goal diversity increases as the number and membership assortment of organizational members involved in the upper echelons of a family firm increases. Consistent with other diversity constructs in organizational literature, goal diversity is proposed as a compositional construct that describes the distribution of goals among the organizational members contributing to decision making in a family firm, and can be captured by the width of the range of goals actively pursued by members of an organization. The fact that the generation of family control and the stage of intra-family succession influence the individual goals of organizational members suggests that succession may also be related to goal diversity in family firms. The analysis at the firm level presented in Figure 2 extends this suspicion. After proxying goal diversity by the number of different goals that emerged from our interviews in each firm, we plotted this on a timeline reporting the time when intra-family succession took place . From this additional analysis emerged that the observed goal diversity is greater in family firms that are temporally closer to the occurrence of an intra-family succession. Insert Figure 2 about here Thus, the imminence of an intra-family succession appears to momentarily disrupt goal diversity, which becomes more perceptible in proximity to generational transitions. Thus, we propose: Proposition 1: Goal diversity is more strongly expressed when an intra-family succession is imminent. To summarize, the findings presented so far reveal that the factors determining organizational member individual goals interact to generate goal diversity. The observations linking individual organizational member goals to the concept of goal diversity and Proposition 1 offer a novel conceptualization of complexity in family firms. This enables recognizing the variety of goals pursued by organizational members belonging to different systems or system interactions. It also allows capturing the degree of organization-level animosity related to goal matters within a family firm while contextualizing the formulation of organizational goals in organization theory to the distinctive case of family firms. In the next section, we uncover the implications of goal diversity for goal formation processes in family firms. --- Professional and Familial Social Interaction Processes To enable understanding goal setting in family firms entailed exploring organizational member individual goals and their determinants, which led us to develop the concept of goal diversity that encapsulates the complex set of inputs to goal formulation processes in family firms. This, however, was only the first step. More importantly, our analysis revealed the means by which organizational member goals are processed in everyday organizational and family life, which were deemed essential to understanding the distinctive features of goal setting in these firms. Family firms are assumed to engage in particularistic behaviors as they place great emphasis on family-centered goals , but how do family firms manage goal diversity arising from family involvement in ownership and management? Our data reveal that goal diversity triggers goal-centered social interaction processes among organizational members, during which we observed the individuals actively making voice and explicitly countering family versus non-family centered goals. In particular, we observed two major stages that characterize the practical patterns through which organizational members interacted : the bargaining mode , and stabilization of their goals . Bargaining was observed when organizational members conveyed interpersonal interactions in the form of either settlements or disputes. Settlements consisted in negotiations of goals among two or more organizational members with symmetrical influences. For instance, a settlement episode was observed during a meeting between a CEO and a minority owner who also serves as a PM. The parties were discussing an issue related to next year's budget and, when the PM expressed some concerns relating to the dividend policy, the two started negotiating until the percentage of profits to be reinvested in the firm was increased. After the meeting, the PM commented: "This is not the first time our views have differed, but after all, we respect each other and both believe we can always find a compromise as long as we want it" . Alternatively, goal divergences were managed through disputes in which typically a more influential party imposed goals on a weaker party during a verbal fight. For example, a recently appointed CEO described when he first asked his father for a share of the firm's equity: "Two years ago it became quite clear that I would take his position sooner or later, so I started telling him about how the company could grow, improve results ... I wanted to become a shareholder to put things in motion, but he was not in favor and left me without much of an explanation … Only now do I understand that he was simply waiting to understand my sister's and my cousins' expectations about the future of the company before making any decision" . In some episodes, but not always, bargaining was followed by a stabilization mechanism observed in the form of formal contracts, agreements and other means through which the goals resulting from a bargaining process were formalized and turned into a consistent course of action for the members involved . Based on this evidence, we thus propose: Proposition 2: The greater the goal diversity, the higher the occurrence of goalcentered social interaction processes. Beyond identifying goal-centered social interactions as processes through which familycentered goals are bargained and stabilized, the most striking part of our evidence was the emergence of two distinct types of social interactions: professional and familial social interaction processes. Strong differences between these two types of goal-centered social interaction processes were clearly evident in terms of settings, norms and means. First, professional social interactions occurred exclusively in the business setting during programmed meetings such as board meetings, management meetings, inter-departmental meetings and formal bilateral meetings. For example, a professional manager was very specific about the arrangement when interacting with a young generation family member he encountered in the corridor: "They must respect my time …Even if the issue was urgent, I told him we could meet another time, I was busy" . To the contrary, familial social interactions were rarely programmed and took place in both business and family contexts, including family councils, private meetings in family member offices, home visits, Sunday lunches and dinners. To illustrate, a young generation family member said: "Sometimes it is also frustrating, I talk about business priorities and objectives at home even more than at the workplace" ; a professional managers said: "Sometimes I visit him [a YG] at home in the evening ... His door is always open to me … The atmosphere is different, I feel relaxed and free to express my concerns" . Furthermore, organizational members taking part in professional social interactions had welldefined roles, as indicated by attire, following hierarchical structures, lack of interruptions and questions asked at the end. To illustrate, organizational members often waited for the appropriate occasion to discuss their concerns through professional social interactions: "I didn't want to disturb him, so I waited until the following Friday for our usual weekly assessment" ; "I waited for the next board meeting to express my concerns" . On the other hand, familial social interactions took place in different circumstances among organizational members with undefined and often ambiguous roles. Individuals started conversations spontaneously while interruptions and distractions were common: "When I have something in mind I just go into his [the CEO's] office and sit down" ; "After dinner … I don't remember how we [the CEO and a PM] started discussing my daughter's career in the firm" . Moreover, professional and familial social interactions contrast administrative with affective bargaining, and formal with social stabilization. In professional social interactions, bargaining took place through promises of rewards and threats of sanctions. When individual goals differed in a professional social interaction, the discussion typically centered on the reciprocal benefits and losses of each member, negotiation followed a top-down flow involving repeated attempts to convince the individuals at the lower levels of organizational hierarchy, often by way of economic benefits. For example, a CEO used economic threats to persuade a non-family shareholder to create a financial instrument to support younger family members: "I was really unhappy with this closure, after all I am the majority owner, I would have preferred to make a joint decision. … I threatened to revise his equity stake" . As a consequence, stabilization in professional social interactions followed the drafting of formal agreements in the form of budgets or contracts, but also binding agreements approved with a simple yet formal handshake. For example, a CEO described an agreement reached with a professional manager as an economic exchange: "I agreed to increased annual marketing investments for the future. But in exchange, I obtained his involvement in training and mentoring two young family members in his department" . In contrast, in familial social interactions bargaining took place through value abstraction and expressions of affect. When individual goals differed, more general topics entered into the discussion while private communication was often used to convince others . Furthermore, individuals tended to calm tension with statements that emphasized their affect or their parental empathy: "I pretended to have more autonomy in a project, as it was important for me personally, and it was for my family too. … People were talking about my low reliability, but my father intervened in my favor by supporting my claims … He said that every one of us must have an opportunity" . In addition, stabilization took place in the form of mores and folkways . During a dinner at the family home, for example, a young generation family manager had an argument with a professional manager. At one point, he was stopped by the father who simply told him: "That's enough, go back to your place". The young manager was immediately silenced. Similarly, in a firm where two brothers were serving as CEOs, folkways were commonly used to resolve conflicts: "After he [his brother] told me what his priorities are, I just accepted them. … As long as we are in charge, I have to trust him; otherwise it will be the end of our firm" . To summarize, the differences that emerged between professional and familial social interactions are reported in Table 3. --- Insert Table 3 about here Collectively, this body of evidence reveals that goal diversity among organizational members is resolved in family firms with two distinct types of interaction processes, namely, professional and familial social interactions. Thus, our analysis provides further insights into the idiosyncrasies of goal setting processes in family firms: Proposition 3: Professional social interactions involve administrative bargaining, whereas familial social interactions involve affective bargaining. Proposition 4: In professional social interactions, stabilization is achieved through formal controls, whereas in familial social interactions stabilization follows social control mechanisms. To sum up, the evidence presented thus far explains how family-centered goals enter the agenda of organizational members in family firms, pointing to two distinct social interaction processes through which family-centered goals are bargained and stabilized, and goal diversity is thus turned into a consistent course of actions to be applied by individual members. In the next section we further explore the consequences of these social interaction processes for organizational outcomes. --- Collective Commitment to Family-Centered Goals The differences between professional and familial social interaction processes have relevant implications on organizational outcomes. The actual implementation of family-centered goals requires organizational members to act on a common set of strategic priorities , and the pursuit of family-centered goals lies at the base of distinctive family firm behaviors . Thus, understanding how family-centered goals are adopted by family firms, notwithstanding organizational member goal diversity, is the ultimate purpose of our study. Our data show that when bargaining was not followed by stabilization, the original goal divergences among organizational members continued to subsist. In contrast, after a stabilization mechanism was observed, the individuals typically communicated their satisfaction and expressed feelings of appreciation and loyalty to family values. For example, after a meeting between a CEO and his daughter who is also involved in the firm, she said, "I needed this confrontation to see the bigger picture and to share his [the CEO's] view" . Likewise, a CEO was pleased about how a discussion with his brother -a shareholder not involved in the firm -was concluded: "When one speaks clearly and sincerely the relationship will benefit both parties. …I will reconsider his [the brother's] position as part of the family" . In addition to organizational members conforming to family values, stabilization also engendered acts of resource dedication, where individuals stated their willingness to invest mental and physical energy towards family-centered goals: "Once I heard the motivations, I understood their importance … I will give my full contribution" ; "A promise is a promise. … Now I know where to direct my efforts" . In sum, the stabilization mechanisms in both professional and familial social interactions resulted in stronger commitment to family-centered goals by the members involved, as observed in terms of conformation to family values and resource dedication . As reported in Table 4, instances of stabilization and the consequent acts of commitment to family-centered goals were observed in both professional and familial social interactions. The range of organizational membership categories of individuals involved is relatively similar for both acts of conformation to family values and resource dedication. More importantly, only 32 percent of professional interactions resulted in an act of commitment to family-centered goals, whereas in familial social interactions, acts of commitment to family-centered goals were observed in 74 percent of episodes. --- Insert Table 4 about here Professional and familial social interactions therefore emerge as two parallel yet distinct processes characterizing goal setting in family firms with different degrees of effectiveness in generating stabilization mechanisms around family-centered goals. In professional interactions, family-centered goals are bargained but are rarely stabilized, and goal diversity often remains unresolved. On the other hand, in familial social interactions the stabilization rate is much higher, suggesting greater effectiveness in bringing together diverse goals and triggering acts of commitment to family-centered goals. Thus, we propose: Proposition 5: Stabilization of family-centered goals is more likely to occur through familial than professional social interactions. The empirical observations presented above were particularly informative on how familycentered goals spread and become accepted among organizational members. We obtained data describing 165 goal-centered social interactions, at least 7 in each family firm. In each firm, both professional and familial social interactions were observed. Each time a stabilization mechanism took place, an organizational member expressed greater commitment to family-centered goals, as denoted by explicit statements indicating either conformation to family values or resource dedication. This evidence formed the premises from which to develop a collective construct to describe the extent to which the individual actions of the organizational members converge towards the accomplishment of family-centered goals. We call this construct collective commitment to family-centered goals: Definition: The collective commitment to family-centered goals is a common mindset and a joint psychological state among family firm organizational members in terms of their feelings of loyalty to the family and the desire to invest mental and physical energy in helping to achieve family-centered goals. Not only did the evidence presented thus far lead us to ground the concept of collective commitment in family-centered goals, but it also revealed several important details on how such commitment develops throughout the organization. Specifically, it showed that organizational members in family firms have the option to confront their goals through either professional or familial social interaction processes. In professional interactions, the family-centered goals are bargained but are rarely stabilized , and goal diversity is not resolved as individuals remain anchored to their own goals and refuse to put their efforts into accomplishing familycentered goals. As a consequence, we propose: Proposition 6: The higher the reliance on professional social interactions, the lower the collective commitment to family-centered goals. To the contrary, familial interactions were often followed by stabilization mechanisms in the form of social controls, which guided individuals to adjusting their own goals, to change their psychological state and to express commitment to family-centered goals . This led us to the interpretation that the formation of family-centered goals in family firms is favored by familial social interactions during which family members create norms of behavior that are consistent with the family vision, increasing organizational member commitment to familycentered goals. As a consequence, commitment to family-centered goals becomes more homogeneous with recurring familial social interactions among organizational members that are repeated over time. Thus, we argue: Proposition 7: The higher the reliance on familial social interactions, the greater the collective commitment to family-centered goals. Based on the body of evidence and the propositions developed so far, in the next section we synthesize our findings to provide a comprehensive portrait of goal setting in family firms. --- Towards a Process View of Goal Setting in Family Firms To help interpret the various concepts and their relationships in our data, we constructed Figure 3, which summarizes and generalizes our main findings, graphically presenting the observations and propositions that emerged from our empirical analysis. --- Insert Figure 3 about here Mirroring the behavioral assumptions of organizational goal setting , our three initial observations describe the family firm as a collective, intended as an interdependent and goal-directed combination of individuals embedded in multiple organizational contexts. The overlap of the family system with ownership and management thus leads not only to the adoption of family-centered goals , but also entails goal diversity, working as a latent force in family firms that may generate resistance to the family coalition. Family firms may resolve goal diversity and promote the adoption of familycentered goals through social interaction processes. However, professional social interactions usually leave intact -and may even exacerbate -goal divergences, thus negatively affecting organizational member commitment to family-centered goals. To the contrary, family-centered goals can be stabilized more effectively through familial social interactions. These promote the resolution of goal divergences between organizational members in favor of the family's interests, and lead to the reinforcement of collective commitment to family-centered goals. Finally, the model in Figure 3 emphasizes the role of intra-family succession as a catalyst of change . When an intra-family succession is imminent, the goals previously stabilized are unfrozen as the leadership and structure are likely to be reconsidered . Thus, organizational members express their goals more fervently and activate social interactions that will lead to new stabilizations, and thus a new status quo, similar to Lewin's classic description of disruptive change as freezing-transition-unfreezing. In sum, our analysis clarifies how the adoption of family-centered goals in family firms stems from a continuous, composite and cyclical process of goal setting among multiple and diverse organizational members. --- DISCUSSION The adoption of family-centered goals is a distinctive trait of family firms and a central axiom in family business literature . Prior research theorized and empirically tested the link between family involvement and the adoption of family-centered goals . However, there is increasing consensus that goals vary among family firms . This calls for more careful attention in untangling the complexity of management processes resulting from systemic interactions between the family, the ownership and the business systems to understand the processes underlying the adoption of family-centered goals and thus improve the predictive power of theories of the family firm. In response, we conducted a qualitative study that provides new insight into how familycentered goals enter the operational agenda of family firms. Our findings disclose the multilevel dimensions of complexity that characterize family firms, adding factual evidence and new notions to our understanding of how multiple and divergent entities generate goal diversity in family firms and how such diversity is managed to create collective commitment to familycentered goals. Specifically, our propositions move the focus of prior research towards an original viewpoint that captures the complexity of goal setting in family firms with the concept of goal diversity. This perspective highlights the critical importance for family firms to manage goal diversity engendered by the unique systemic interactions between the family, the ownership and business systems. In this vein, the framework derived from our findings outlines two distinct social interaction processes through which goal diversity can be managed to build collective commitment to family-centered goals. While prior research primarily focused on family members pushing family-centered goals into the family firm agenda, our propositions suggest that for family-centered goals to be taken into consideration and affect the firm's strategic actions, these must be shared and embraced by a broader set of organizational members including, for example, professional managers as well as non-family shareholders. Finally, our propositions call attention to intra-family succession as a catalyst of change for organizational goals in family firms, thus offering an original portrait of goal setting that incorporates the multidimensional, dynamic and cyclical aspects of goal setting processes in family firms. Our findings have theoretical and empirical implications. While family involvement in ownership and management remains a general predictor of the ability of a controlling family to influence the policies and decisions of a firm , the active participation of family members in the business is also shown to produce greater goal diversity among organizational members. This diversity may entail conflict among family and non-family managers, family and non-family shareholders, as well as among family members in different generations or with different degrees of involvement. Goal diversity is an accurate and fitting representation of the varied relations between the family, ownership, and business systems and points to the existence of new mediating mechanisms between family involvement and the adoption of family-centered goals. On the one hand, we show that familial social interactions act as a consistent mediator of the relationship between goal diversity and collective commitment to family-centered goals; on the other hand, professional social interactions act as an inconsistent mediator of the same relationship. A more careful account of goal diversity in family firms and the internal processes of social interactions among organizational members would benefit the development of theories on the distinctive behaviors of family firms. Considering the causes and consequences of goal diversity within the family firm as a whole, or within specific decisional groups would enable a better prediction of the conditions under which family involvement in ownership and management lead to the adoption of familycentered goals in decision making . Furthermore, taking into consideration goal diversity and professional and familial social interactions would also benefit the accuracy of empirical research. Indeed, while the inclusion of a consistent mediator in a statistical model will reduce the main effect, the inclusion of an inconsistent mediator is acknowledged as increasing its predictive validity . Our study also adds to our knowdge of intra-family succession processes and indicates the decisive effects of intra-family succession for family-centered goals. Intra-family succession is one of the key topics in family business literature as this poses unique challenges for family firms. Our study adds to previous work in this sphere by showing that the imminence of a generational transition increases the expression of goal diversity in the organization and triggers unfreezing processes in relation to the previously stabilized goals and restabilization of new organizational goals, thus disentangling the dynamic and iterative nature of intra-family succession . In addition, our study has practical implications for families who wish to sustain the creation of wealth across generations of family control, finding in our model practical advice on the importance of establishing and managing goal setting processes during the intra-family succession phases. More broadly, managers and professionals working with family firms could make use of our findings to build practical solutions for business families wanting to spread family values and build collective commitment to family-centered goals in their firms without incurring relational conflicts with other organizational members. A more extensive use of familial social interactions could in fact be a viable pathway to building legitimacy for the controlling family and obtaining positive outcomes for both the business and the family. To the contrary, the exclusive discussion of family-centered goals through professional social interactions may be an ineffective -and possibly counterproductive -way to advance the values and vision of the family in the firm. Finally, our findings also encourage family firm advisors to more carefully implement conflict-resolution strategies in family firms since their effectiveness must be adjusted and contextualized to the different types of social interactions as emerging from our study. --- Limitations and Future Research Directions Our study is a first step to uncovering the intervening mechanisms that characterize goal setting in family firms, however, as any other qualitative study, it has a number of limitations that lay the foundations for future research. One area that deserves particular attention is the external validity of our findings, which must be tested and refined with statistical considerations. Our experience suggests that collecting data on goal setting processes in the family firm is difficult due to time and access constraints; therefore, creative approaches and innovative experimental designs are needed. Future research aspirations include capturing and linking the multiple notions proposed in this study with quantitative work in real and practical settings of how organizational goals are determined. In relation to this, our purpose was to introduce new constructs to explain how organizational goals are formed in family firms, but refining and validating these constructs is outside of the scope of this article. Refining the original constructs proposed in this article and developing reliable scales to measure these constructs is thus proposed as a promising area for future research. For example, the construct of goal diversity requires further examination and more work is required to advance our understanding of its antecedents and consequences by exploring its meaning, its maximum shape and the potential existence of distinct types of goal diversity . Future research will further advance our understanding of internal dynamics in family firms if it factually models the relative influences among individual organizational members. Indeed, we recognize that organizational members of family firms may have different degrees of organizational discretion to influence the goal setting process. The theory of stakeholder salience , for example, could serve as a starting point to address this issue. Finally, we intentionally restricted our analysis to small and medium family firms. Although our focus allowed us to investigate goal formulation processes in an ideal situation where the influence of the controlling family is potentially more important than in other firms, we may have overlooked those family firms where greater organizational complexity could potentially lead to even greater goal diversity among organizational members. For similar reasons, while we only focused on the organizational members in family firms within the ownership, business and family domains, future research is encouraged to extend our line of thinking to other actors that could presumably influence the goals pursued by these organizations. In addition to extending the external validity and generalizability of our findings, and relying on the notions introduced in this study to build new measurable constructs, future research could draw from the insights provided in this study to address interesting and unexplored questions that are relevant for the development of knowledge on family firms. In particular, our observation that family involvement entails superior goal diversity in the organization introduces a new perspective to the study of family firms and stimulates further research in the area of organizational behavior in family firms. For example, prior research emphasized the importance of conflicts engendered by goal incompatibilities and divergences between individuals with diverse social identities and different goals on the perceived injustice of family and non-family members. This suggests that goal diversity in the family firm could have important implications for several organizational outcomes such as organizational citizenship, person-organization fit or cognitive uncertainty. To our knowledge, studies on organizational behavior in family firms are scarce, however, the existence of unique sources of complexity in the family firm organizational environment suggests that research in this area could benefit understanding of organizational behavior in family firms and refining organizational behavior theories. For instance, how do family and nonfamily members choose between professional and familial interactions? How are these two social interaction processes engaged in over time? Although outside the scope of our research, these could represent promising research questions for future studies to understand how behaviors such as voice, whistle-blowing, championing or issue selling occur in family firms. --- CONCLUSION Although family firms, as any other business organization, must focus their efforts on achieving positive economic performance, the unique and systemic conditions arising in family firms due to the interaction of the family unit, the business entity and individual family members, increase the complexity of strategy processes and performance outcomes. Accordingly, we have sought to illuminate the overlooked topic of goal setting in family firms. Understanding how multiple and competing goals enter the decision processes of family firms is critical for management scholars as well as practitioners. We ascertained the complexities and challenges of goal setting in family firms and developed a grounded framework that describes goal setting as a set of multiple concurrent processes, emphasizing the triggering role of intra-family succession. This adds to our knowledge of the link between family involvement and the adoption of familycentered goals, pointing to promising avenues for future research while offering practical insights on goal setting in family firms. We hope to have brought research and practice closer to understanding the unique constituencies of family firms and to effectively managing their idiosyncratic strategic processes. a Percentages refer to the percentage of professional interactions concluded by stabilization; 92 total episodes. b Percentages refer to the percentage of familial interactions concluded by stabilization; 73 total episodes. --- APPENDIX --- Figure 1 Overview of Data Structure a a All data were derived from semi-structured interviews; "m" indicates "supplemented with meeting observations"; and "d" indicates "supplemented with archival data". --- Second-Order Themes First-Order Codes Aggregate Theoretical Dimensions Goal Content Organizational members discussing the nature of their goals for the firm m Goal Categories --- Behavioral Relevance of Goals Organizational members discussing who the prime beneficiary of their goals is m Goal Recipient Organizational members referring to a goal as meaning "successful", "right" or "pleasant" m --- Goal Meaning Statements such as "it is important" or "I care" referred to a goal m Goal Importance Organizational members cited in documents that explicitly describe constrains to the members' or to the organization's behavior

Goal setting in family firms is very complex due to the interplay between family and business systems. However, this topic is largely overlooked in family business research. In this qualitative study of goals and goal formulation processes among 76 organizational members across 19 family firms, we identify goal diversity as a direct consequence of the overlap between the family, ownership and business systems. We found that goal diversity is expressed more strongly in the proximity of generational transitions, triggering social interaction processes through which organizational members contrast their goals. Our findings suggest that different types of social interactions lead to different behaviors, with familial social interactions being more effective than professional social interactions in managing goal diversity toward the formation of collective commitment to family-centered goals.

Introduction --- Work-Family Conflict and Depressive Symptoms among Chinese Employees: Cross-Level Interaction of Organizational Justice Climate and Family Flexibility Work-family conflict is defined as "a form of interrole conflict in which the role pressures from the work and family domains are mutually incompatible in some respect" . In China, with women's entry into the workforce, the traditional gender roles of breadwinning men and homemaking women are changing. This civilian labor trend increases the likelihood that both men and women face simultaneous management of work and family issues across the life span [2]. In addition, companies put forward high demand for employees in this highly competitive business world. Thus, employees are facing problems of how to balance their work and family lives and suffer from work-family conflict, which may result in depressive symptoms. As an important aspect of --- Work-Family Conflict and Depressive Symptoms Role theory provides a useful framework to understand work-family conflict [2]. This theory proposes that an individual may lack the time and energy to meet obligations of both work and family. Simultaneous occurrence of work and family roles might result in an increased likelihood of role conflict, overload, and other negative outcomes [7]. Considering the directionality, work-family conflict includes two dimensions of work-to-family conflict and family-to-work conflict [8]. WFC describes the situation in which the demands of one's job interfere with family-related responsibilities. Conversely, FWC describes the situation in which the demands of one's family interfere with work-related responsibilities. Previous studies have shown that WFC and FWC are two different constructs [4]. In this study, the term work-family conflict refers to the conflict between work and family, without referring to directionality. The terms WFC and FWC depict the directionality of conflict between work and family. Studies in Western culture have demonstrated that individuals experienced more depressive symptoms as their WFC or FWC increased [9][10][11]. In China, with the rapid growth of China's economy and the shift of traditional gender roles at home and work, the work-family conflict level of both male and female employees has increased significantly over the past years [12]. It is necessary to conduct more research on Chinese employees' work-family conflict and mental health. However, there are only few studies that reported the association between work-family conflict and depressive symptoms in Chinese context. One study on Chinese bank employees found that WFC was positively associated with depressive symptoms [13]. In another study, Chinese professional women's WFC was positively associated with their depressive symptoms [14]. Another study on Chinese female nurses found that both WFC and FWC contributed to more depressive symptoms [15]. However, little information is known about the association between work-family conflict and depressive symptoms among Chinese employees in the engineering construction industry. According to the general stress models, a lack of fit at the interface of work and family roles represents a potent stressor that might induce serious mental health problems, such as depressive symptoms [16]. Some studies have distinctively examined the association between WFC or FWC and mental health, because someone may put work before family, while others may value family more importantly than work, thus WFC and FWC may have different impact on employee health outcomes. For example, Frone et al. [17] found FWC was longitudinally related to poor physical health and more depressive symptoms, while WFC was longitudinally related to more heavy alcohol consumption. While other studies found WFC and FWC had similar effects on mental and somatic health [18]. On the whole, both types of conflict go against to employees' mental health but sometimes with difference in the magnitude of adverse effect. However, we have little information about whether WFC and FWC had the same effect on depressive symptoms in Chinese context. Thus, we focused on Chinese employees in the engineering construction industry and simultaneously examined the effect of the two dimensions of work-family conflict-WFC and FWC on their depressive symptoms and hypothesized the both types of conflict would be positively associated with depressive symptoms. --- Work-Family Conflict and Depressive Symptoms: The Role of Organizational Justice Climate According to the ecological system perspective, individual work-family experience is nested within work and family contexts [19]. Bronfenbrenner's ecological systems theory suggests that work-family experience reflects the adequacy fit between the individual and his or her environment, which is influenced by process, person, context, and time characteristics [20]. Work-family conflict is often associated with contextual factors in both work and family microsystems, such as work or family pressure [19]. Previous studies also identify many ecological resources such as decision latitude in work, support from coworkers and supervisors, spouse and other family affectual support in work-family interaction process [19]. However, limited studies have considered organizational justice climate and family flexibility as the ecological resources in work-family experience. Organizational justice describes employees' subjective perceptions of fairness in their work settings, which is an important contextual factor associated with the interface of work and family [21]. Organizational justice includes four dimensions: procedural justice, distributive justice, interpersonal justice, and informational justice [22]. Procedural justice emphasizes the unbiased decision-making processes in which the interests of everyone should be taken into account. Distributive justice emphasizes the fairness of decision outcomes in which the proportion of investments and outcomes should be consistent for all employees. Interpersonal justice considers the extent to which employees are treated with sincerity and respect by their supervisors. Informational justice refers to adequate and honest explanations about decisions and procedures [22,23]. Organizational justice has been termed as a psychosocial predictor of employees' psychological and physical health [21,24,25]. Perceived organizational justice could reduce uncertainty and lack of control and in turn reduce the feeling of stress [23]. For example, Ybema and Bos [26] found that distributive justice and procedural justice reduced depressive symptoms in a longitudinal study. Inoue et al. [27] found that low procedural justice and interactional justice were significantly associated with major depressive episodes in Japanese employees in a cross-sectional study. However, these studies have predominantly examined the associations between justice perceptions and depressive symptoms at the individual level. Recent studies have constructed justice as a collective or group-level concept, which is defined as the justice climate, the degree of fairness perceived by the team as a whole [28,29]. The collective view of justice is based on social interaction, which influences individual perceptions of organizational justice within teams [30]. Building on the social construction of justice perception, justice climate has been defined as group and organizational-level justice perceptions. Workers are expected to be happier when group members believe that they are treated fairly [30]. However, previous studies adopted an individualistic approach to research organizational justice, which fails to take full account of the social context within justice perceptions are shaped [28]. The justice climate is shared through social interactions among individual employees within a work group [28]. According to the social contagion theory, justice climate at the group level would go beyond justice at the individual level to affect individual-level outcomes such as attitudes, behavior, and mental health [30,31]. For example, Spell and Arnold [30] found that distributive and procedural justice climates had a significant influence on employees' anxiety and depressive symptoms, in addition to the effect of individual perceptions of justice. Lucas et al. [29] found that the justice climate could strengthen the associations between individual-level justice perceptions and personal well-being. In Pecino et al. [32], interpersonal justice climate in a work team was significantly associated with well-being indicators and work outcomes . Employees work in a department with poor justice climate reported more somatic complaints [33]. Organizational justice could not only show a direct positive effect on mental health but also protect employees from the negative effects of workplace risk factors. For example, in a longitudinal study, Gluschkoff et al. [34] found that teachers' perceptions of organizational justice would weaken the negative effect of workplace violence on their sleep problems. According to the resources conservation model, justice could strengthen individuals' resources to effectively deal with stress and reduce their vulnerability to stress reactions [21]. In addition, the organizational justice climate could provide a supportive work environment and enhance social interactions among coworkers [28]. In summary, most of previous studies concept organizational justice as a protective factor for employees' mental health at individual level, but we have limited knowledge about how an organizational justice climate as a work environment variable protects employees from the negative impacts of work-family conflict. Although work causes conflicts with family issues, a justice work environment could respect employees' contributions and treat employees fairly, employees might feel that work devotion is worth it. Similarly, in a situation in which family issues interfere with work-related responsibilities, a justice work environment could give employees support and make them feel at ease. Thus, work-family conflict would be less stressful in a justice work environment. We hypothesized that an organizational justice climate would protect employees from depressive symptoms induced by work-family conflict. --- Work-Family Conflict and Depressive Symptoms: The Role of Family Flexibility Boundary flexibility is conceptualized as the degree to which an individual can be drawn out of one domain to meet the demands of the other domain, either behaviorally or cognitively [35]. Segmentation and integration are two opposite ends of the segmentation-integration continuum, which characterizes the interface between work and family [36]. When work and family are segmented, the flow between domains is minimized, resulting in reduced domain blurring. On the contrary, when work and family are highly integrated, the flow between domains is maximized, facilitating transitions between domains. According to boundary theory, people develop distinct boundaries around work and family domains [37]. For example, an individual may allow work to flow into the family domain but not allow family to enter the work domain. This highlights the idea that work flexibility and family flexibility are two distinct dimensions of boundary flexibility. Employees who perceive low boundary flexibility may have difficulties in managing the work-family interface because it interferes with the flow between the two domains. Previous studies have mainly emphasized the importance of work boundary flexibility for reducing work-family conflict. For example, Ferguson et al. [38] found that work boundary flexibility including supervisor instrumental support and organizational segmentation support enhanced family functioning, organizational commitment, and marital satisfaction. However, limited studies have examined the role of family boundary flexibility in work-family conflict due to the lack of formal policies in families [35]. Family flexibility could function as a resource to address stressors that arise from the work-family interface [37]. The family boundary is more flexible; there are more positive spillovers from home to work [35]. In addition, with higher family flexibility, individuals could have more communication with family members about work, which enhances work and family balance [39]. Thus, family flexibility might protect employees from suffering depressive symptoms induced by work-family conflict. The protective role of organizational justice climate in mental health outcomes may depend on family flexibility. From the ecosystem perspective, work-family experience is a joint function of work and family characteristics. Organizational justice climate and family flexibility can be seen as ecological resources in work and family microsystems, respectively. Communication with family about work and communication with work associates about family are associated with better work and family function, as well as higher work and family satisfaction [39]. Employees with different family roles may have different reactions to organizational support [40]. Those with high family flexibility could flexibly arrange their family tasks and receive sufficient support from family members to ease work-family conflict. However, those with multiple family roles and lack of family flexibility might impose high demands for a family-supportive organization [40]. Thus, employees with low family flexibility are more likely to turn to organizations for help when suffering from work-family conflict, and those with high family flexibility might be less reactive to organizational support. Therefore, we hypothesized that the buffering effect of organizational justice climate in the association between work-family conflict and depressive symptoms would be stronger in conditions of low family flexibility than that in conditions of high family flexibility. --- Study Hypotheses According to the work and family interface theory, work-family conflict including both WFC and FWC could be risk factors for employee depressive symptoms. From the ecological perspective, contextual factors in both work and family microsystems are associated with individual work-family experience [19,41]. We identified organizational justice climate and family flexibility as protective factors in work and family settings, respectively, and hypothesized that : --- Study Hypotheses According to the work and family interface theory, work-family conflict including both WFC and FWC could be risk factors for employee depressive symptoms. From the ecological perspective, contextual factors in both work and family microsystems are associated with individual work-family experience [19,41]. We identified organizational justice climate and family flexibility as protective factors in work and family settings, respectively, and hypothesized that : --- Hypothesis 1: Work-family conflict would be positively associated with depressive symptoms. Hypothesis 2: Organizational justice climate would be negatively associated with depressive symptoms. Hypothesis 3: Organizational justice climate would buffer the association between WFC/FWC and depressive symptoms. That is, compared with employees from groups with low justice climate, the association between WFC/FWC and depressive symptoms would be weaker for employees from groups with high justice climate. --- Hypothesis 4: The buffering effect of organizational justice climate in the association between WFC/FWC and depressive symptoms would be influenced by family flexibility. Specifically, this buffering effect in conditions of low family flexibility would be stronger than that in conditions of high family flexibility. --- Materials and Methods --- Participants and Procedure Our participants come from a large state-owned enterprise controlled by the Chinese government. The enterprise is an engineering construction industry and provides engineering, technology, production, sales and other services. As one of the largest Chinese domestic engineering construction companies, this enterprise has many subsidiaries across mainland China. We chose this enterprise as our study sample, because this enterprise is very big and we can get enough participants to test the cross-level interaction. In addition, the subsidiaries in this enterprise have similar organizational structure and management mode, thus the other objective variables in the organization are naturally kept constant, and we can better examine the effect of organizational justice climate at the department level on work-family conflict and depressive symptoms. As this is a very big enterprise in China and employees in this enterprise face high-intensity work and great work pressure, each subsidiary has an occupational disease center. The survey was completed with the assistance of the occupational disease prevention center at each subsidiary. The Hypothesis 2: Organizational justice climate would be negatively associated with depressive symptoms. Hypothesis 3: Organizational justice climate would buffer the association between WFC/FWC and depressive symptoms. That is, compared with employees from groups with low justice climate, the association between WFC/FWC and depressive symptoms would be weaker for employees from groups with high justice climate. --- Hypothesis 4: The buffering effect of organizational justice climate in the association between WFC/FWC and depressive symptoms would be influenced by family flexibility. Specifically, this buffering effect in conditions of low family flexibility would be stronger than that in conditions of high family flexibility. --- Materials and Methods --- Participants and Procedure Our participants come from a large state-owned enterprise controlled by the Chinese government. The enterprise is an engineering construction industry and provides engineering, technology, production, sales and other services. As one of the largest Chinese domestic engineering construction companies, this enterprise has many subsidiaries across mainland China. We chose this enterprise as our study sample, because this enterprise is very big and we can get enough participants to test the cross-level interaction. In addition, the subsidiaries in this enterprise have similar organizational structure and management mode, thus the other objective variables in the organization are naturally kept constant, and we can better examine the effect of organizational justice climate at the department level on work-family conflict and depressive symptoms. As this is a very big enterprise in China and employees in this enterprise face high-intensity work and great work pressure, each subsidiary has an occupational disease center. The survey was completed with the assistance of the occupational disease prevention center at each subsidiary. The staff at these centers were trained in conducting psychological surveys. We explained in detail to them how to guide their employees to complete the survey. We distributed questionnaire at each department's all-hands meeting and all the employees gave their informed consent for inclusion before participating in this study. The survey took about 30 min. Research assistants collected questionnaires right after their completion. Participants do not necessarily to provide their real name but they could write down their nickname that only they know on the first page of the questionnaire. After 3 months, with the information of enterprise, gender, and nickname, participants could obtain a personal feedback report about their own mental health status. There is no remuneration for their participation in this survey, but they can get a personal feedback as an incentive. In addition, the personal feedback can motivate them to answer the questionnaire seriously and faithfully. This study was conducted in accordance with the Declaration of Helsinki, and all subjects gave their informed consent for inclusion before participating in this study. As this piece of research in not, by its nature, a clinical experiment, thus it is not necessary to be adjudicated by the Research Ethics of Committee. This study was conducted in six subsidiaries of this company, and we invited all the employees to participate in this study. Finally, 2365 employees from 103 departments participated in this study. The response rate was 78%. We eliminated departments with fewer than 10 members . As a result, this study included 2184 employees from 76 departments in the data analysis. Each department had an average of 29 employees . The participants had an average age of 42.38 years , and 65% of them were male. The sociodemographic information of participants is displayed in Table 1. Note. 1 USD = 6.5 RMB . SD = standard deviation. --- Measures The questionnaire contained participants' sociodemographic information, including sex, age, marital status, education, income, and tenure. Work-family conflict was measured with the work-family conflict scale developed by Netemeyer et al. [8]. This scale contained 10 items, with five assessing WFC and five assessing FWC . Participants indicated their responses on a 5-point Likert scale, ranging from 1 to 5 . Higher scores on the two subscales indicated higher levels of WFC and FWC, respectively. In this study, Cronbach's alpha coefficients for WFC and FWC subscales were 0.88 and 0.83, respectively. Organizational justice was measured with the 20-item justice scale developed by Colquitt [22]. This scale contained four distinct dimensions, including procedural justice , distributive justice , interpersonal justice , and informational justice . Responses ranged from 0 to 4 . Higher scores on this scale indicated higher justice perception. In this study, Cronbach's alpha coefficients for procedural, distributive, interpersonal, and informational justice subscales were 0.88, 0.90, 0.87, and 0.89, respectively. Aggregating individual responses about justice perceptions to group level is a common approach to operationalization of climate [28]. Thus, in this study, justice climate was measured by averaging each group member's justice perceptions within the work group. Family flexibility was measured with the work and family domain boundary flexibility scale developed by Matthews and Barnes-Farrell [37]. The family flexibility-ability subscale consisted of five items . Items were rated on a 5-point Likert scale, ranging from 1 to 5 . A higher score on this scale indicated higher family flexibility. In this study, the Cronbach's alpha coefficient for the family flexibility scale was 0.92. Depressive symptoms were measured with the Patient Health Questionnaire for Depression [3]. This scale has been widely used to measure depressive symptoms. The measurement contained nine items describing depressive symptoms . Participants were asked, "Over the last two weeks, how often have you been bothered by any of the following problems?" The responses were indicated by 0 , 1 , 2 , or 3 . Higher scores on the PHQ-9 indicated more depressive symptoms. In this study, the Cronbach's alpha coefficient for the scale was 0.90. --- Statistical Analysis We used hierarchical regression models to analyze the data, with the individual-level dependent variable regressed on individual-level independent variables and the group-level independent variable . Our hypotheses made predictions about individual-level and group-level variables and their interactions in relation to individual-level depressive symptoms. Before testing these hypotheses, the intraclass correlation , which describes the proportion of between-group variance to the total variance, was calculated for the dependent variables. We began the analysis by determining intercept and slope terms describing the relationship between predictors and dependent variables in each work group. The intercept and slope terms from this analysis were then used as the dependent variables in between-group analysis. Sociodemographic variables were used as control variables at the individual level, and group size was used as a control variable at group level. We performed the analyses using the Mplus 7.0 program . To further interpret the moderating effects with figures, high and low levels of moderators were defined as one standard deviation above and below the mean of organizational justice climate and family flexibility, respectively. --- Results We conducted a confirmatory factor analysis with items loading on its respective variables. The model fit indexes were χ 2 = 8240.437, RMSEA = 0.061, CFI = 0.889, TLI = 0.882, SRMR = 0.060, and the factor loadings of each item ranged from 0.5 to 0.8. We used the bifactor model to test common method variance with all the items loading not only on the construct they belong to, but also on a same latent factor of common method variance. The results showed that the model with latent factor of common method variance cannot be identified, indicating common method variance factor is not reasonable in this data. The ICC for depressive symptoms was 0.042 , which means 4.2% variance of depressive symptoms existing at the group level. Similarly, the ICCs for procedural justice, distributive justice, interpersonal justice, and informational justice were 0.034, 0.032, 0.035, and 0.032 , respectively. In a previous study, an ICC of 2% was an acceptable size to justify the use of multilevel analysis [42]. In another study, an ICC of 1.6% was an acceptable size for use of multilevel analysis [43]. Because this study focused on the effect of justice climate at the group level on employee depressive symptoms, it was necessary to use hierarchical linear modeling to address the variance at different levels. At the individual level, individuals' perceptions of WFC and FWC were positively associated with their depressive symptoms. Individuals' perceptions of justice were negatively associated with depressive symptoms . Family flexibility was negatively associated with depressive symptoms . At the group level, the collective perceptions of justice were negatively associated with the mean level of depressive symptoms in a certain group . Descriptive statistics and bivariate correlations between the study variables are shown in Table 2. We conducted hierarchical regression analysis for both WFC and FWC. Table 3 presents the relationship between WFC and depressive symptoms with organizational justice climate and family flexibility as moderators. The results for FWC and depressive symptoms are presented in Table 4; they are similar to the results of WFC and depressive symptoms in Table 3. WFC and FWC were positively associated with depressive symptoms after controlling for the sociodemographic variables. Thus, Hypothesis 1 was supported. Organizational justice climate was negatively associated with individual-level depressive symptoms . Thus, Hypothesis 2 was supported. In addition, the cross-level interactions of WFC and each dimension of organizational justice climate were significant in predicting depressive symptoms. Decomposing the interaction effect in Figure 2, compared with individuals from groups with low justice climate, the relationship between WFC and depressive symptoms was weaker for individuals from groups with high justice climate. The results for the cross-level interactions of FWC and organizational justice climate were similar to the results of WFC. These results indicated that organizational justice climate could weaken the positive association between work-family conflict and depressive symptoms. Thus, Hypothesis 3 was supported. The three-way interactions of WFC × Procedural justice climate × Family flexibility and WFC × Distributive justice climate × Family flexibility were significant, whereas the three-way interactions of WFC × Interpersonal justice climate × Family flexibility and WFC × Informational justice climate × Family flexibility were not significant in predicting depressive symptoms . Decomposing the interaction of WFC × Procedural justice climate × Family flexibility , when family flexibility is low, the interaction of WFC × Procedural justice climate is significant, whereas when family flexibility is high, the interaction of WFC × Procedural justice climate is not significant in predicting depressive symptoms. The interaction pattern of WFC × Distributive justice climate × Family flexibility was similar to the pattern of WFC × Procedural justice climate × Family flexibility. The results for FWC and depressive symptoms are presented in Table 4; they are similar to the results of WFC and depressive symptoms in Table 3. These results indicate that the buffering effects of procedural and distributive justice climate in the association between work-family conflict and depressive symptoms became stronger as family flexibility decreased, whereas the buffering effects of interpersonal and informational justice climate were not influenced by family flexibility. Thus, Hypothesis 4 was supported for procedural and distributive justice climate, but not for interpersonal or informational justice climate. The three-way interactions of WFC × Procedural justice climate × Family flexibility and WFC × Distributive justice climate × Family flexibility were significant, whereas the three-way interactions of WFC × Interpersonal justice climate × Family flexibility and WFC × Informational justice climate × Family flexibility were not significant in predicting depressive symptoms . Decomposing the interaction of WFC × Procedural justice climate × Family flexibility , when family flexibility is low, the interaction of WFC × Procedural justice climate is significant, whereas when family flexibility is high, the interaction of WFC × Procedural justice climate is not significant in predicting depressive symptoms. The interaction pattern of WFC × Distributive justice climate × Family flexibility was similar to the pattern of WFC × Procedural justice climate × Family flexibility. The three-way interactions of WFC × Procedural justice climate × Family flexibility and WFC × Distributive justice climate × Family flexibility were significant, whereas the three-way interactions of WFC × Interpersonal justice climate × Family flexibility and WFC × Informational justice climate × Family flexibility were not significant in predicting depressive symptoms . Decomposing the interaction of WFC × Procedural justice climate × Family flexibility , when family flexibility is low, the interaction of WFC × Procedural justice climate is significant, whereas when family flexibility is high, the interaction of WFC × Procedural justice climate is not significant in predicting depressive symptoms. The interaction pattern of WFC × Distributive justice climate × Family flexibility was similar to the pattern of WFC × Procedural justice climate × Family flexibility. --- Discussion This study examined the association between work-family conflict and depressive symptoms among Chinese employees in the engineering construction industry and further examined how organizational justice climate and family flexibility attenuate the negative effect of work-family conflict using hierarchical regression models. We found that both WFC and FWC-the two dimensions of work-family conflict were positively associated with employees' depressive symptoms . Organizational justice climate was negatively associated with employees' depressive symptoms , and further attenuated the association between work-family conflict and depressive symptoms . Moreover, the protective role of organizational justice climate depended on family flexibility. Procedural and distributive justice climate can buffer the negative effect of work-family conflict only for employees with low family flexibility but not for those with high family flexibility . This study provided more evidence about work-family conflict and mental health in a Chinese context. By including WFC and FWC simultaneously, this study found that the conflict between work and family regardless of the directionality could induce employees' depressive symptoms, which is consistent with most previous findings in Western culture. However, Frone et al. [17] found that FWC was related to more depressive symptoms, but WFC was unrelated to depressive symptoms, according to longitudinal data over 4 years. Our findings were similar with Hao et al. [15], in that both WFC and FWC contributed to more depressive symptoms. As a general emotional state, depressive symptoms would be induced by both WFC and FWC in this study. These results indicate that work and family contexts are fairly important to Chinese employees. Disturbed responsibility in either field would induce employees' depressive symptoms. Additionally, the relative importance of work and family might change with time. It is reasonable for results among studies conducted in different times and contexts to be inconsistent. Moreover, due to the cross-sectional design of this study, whether WFC and FWC showed the same effect on depressive symptoms in longitudinal studies needs further examination. At any rate, interventions aimed at reducing the conflict between work and family are beneficial to promote Chinese employees' mental health. China is facing rapid economic development and social changes; Chinese employees' work-family experience is an important issue. Whether WFC and FWC had the same effect on Chinese employees' mental health needs further exploration. This study integrated the organizational justice theory into work-family interface and identified organizational justice climate as an important ecological resource in work environment which would influence employees' work-family experience. Consistent with the ecological perspective in Grzywacz and Marks [19], work-family experience is a joint function of process, person, work and family context. However, previous studies rarely considered the role of organizational justice climate in work-family experience, and we fill this gap in this study. By taking a collective view of justice, we found that organizational justice climate could protect employees from depressive symptoms. These results indicate that in addition to individual justice perception, justice climate at the group level played an important role in employees' mental health, which is consistent with previous studies [21,24,25]. In addition, this study found that organizational justice climate weakened the positive association between work-family conflict and depressive symptoms, which indicates that organizational justice climate could protect employees from depressive symptoms induced by WFC and FWC. Previous studies mainly focused on family-supportive organizations to reduce work-family conflict [40,41]. This study indicates that organizational justice climate could be seen as a supportive atmosphere. Employees who perceive their organizations as fair are more responsive to work-family tensions [21]. Aside from suggestions such as flexible working hours mentioned in previous studies [40,41], cultivating a justice atmosphere in an organization is helpful to mitigate the negative effect of work-family conflict. We also integrated boundary flexibility theory into work-family interface to further understand how organization and family factors influence employees' work-family experience by simultaneously examining the ecological resources in work and family microsystems [19]. We found that family flexibility could protect employees from the negative outcomes of work-family conflict, which was consistent with previous studies [37,39]. Although family flexibility could not directly weaken the adverse effect of work-family conflict on depressive symptoms, it influenced the moderating effect of organizational justice climate in the association between work-family conflict and depressive symptoms. These results indicate that organizational justice climate and family flexibility could compensate each other to protect employees from depressive symptoms induced by work-family conflict. Specifically, for employees with low family flexibility, organizational justice climate played the dominant role in protecting them from depressive symptoms induced by work-family conflict. For employees with high family flexibility, family flexibility played the dominant role in mitigating the adverse effect of work-family conflict. Family flexibility could reduce time-and strain-based spillover from home to work and work to home [35]. High family flexibility could make transitions between work and family easier, thus mitigating work-family conflict. For example, in the situation in which an employee has to work late, if the employee's family members could take on family responsibilities for him or her, the work-family conflict could be reduced. However, employees who lack family flexibility are more likely to rely on organizations to mitigate the adverse effects of work-family conflict. Thus, organizations and families should work together to promote employees' mental health. Interestingly, we found that the four dimensions of organizational justice climate showed different results in the three-way interaction analysis. The moderation effects of procedural and distributive justice climate on depressive symptoms depended on family flexibility, whereas that of interpersonal and information justice climate on depressive symptoms did not depend on family flexibility. In other words, family flexibility could compensate for the protective role of procedural and distributive justice but not interpersonal and informational justice. Interpersonal justice and informational justice are also called interactional justice, which is a unique dimension of justice [22]. Interactional justice describes whether decision makers treat people with respect and sensitivity and explain the rationale for decisions thoroughly; whereas procedural and distributive justice care more about the interests and outcomes [22,23]. These findings may indicate that the interpersonal and informational aspects of justice play a unique role in the work-family interface, which could not be replaced by family flexibility. The role of each aspect of organizational justice in work-family experience needs further exploration. --- Implications Findings from this study have some implications for reducing the negative consequences of work-family conflict for employees in the engineering construction industry. As the rapid development of construction projects in China, the occupational health of construction workers need more attention. We found their work-family conflict is a serious issue, and interventions at individual, family, and organizational levels should be combined to manage employees' work-family conflict. First, organizations should cultivate a justice atmosphere in the work setting. For example, organizations could provide employees with opportunities to have a voice and participate in decision-making processes. Supervisors should treat employees with courtesy and respect and act fairly toward all employees. In addition, organizations could create friendly policies, such as flexible hours, to reduce employees' work-family conflict. Organizations should cultivate a supportive and friendly work environment and provide financial and social support to employees who suffer from family problems. Organizations could provide mental health services to employees who suffer from depressive symptoms. Besides organizational justice climate, other organizational factors such as organizational structure and work arrangement in alleviating work-family conflict can be considered in future studies. Second, employees' work-family conflict and depressive symptoms could be reduced by enhancing their family flexibility. Spouses should promote mutual support and understanding and share family responsibilities, such as housework and taking care of children. These findings hint that family flexibility is an essential condition for construction workers. Future studies may take other family characteristics such as spouse's characteristics into work-family conflict research. Lastly, organizations and family members could provide support to enhance employees' ability to manage and flex the boundaries between work and family. In China, now employees' mental health is not compulsively monitored by an occupational doctor. The provision of mental health service is not mandatory in Chinese legislation but is up to the enterprise. Thus, enterprises should consider personalized interventions to reduce employees' work-family conflict and depressive symptoms. For example, enterprises should pay more attention to employees who lack family flexibility. --- Limitations We have to acknowledge some limitations in this study. First, although we theoretically identified work-family conflict as the antecedent of depressive symptoms, we cannot infer a causal relationship between work-family conflict and depressive symptoms with this cross-sectional design, which can be tested in future longitudinal or experimental studies. Second, the variables in this study were assessed with self-reported data, but fortunately, we statistically tested the common method bias to be nonsignificant. Future studies may consider multiple data source. Third, this study was conducted in Chinese engineering construction industry. Whether the results can be generalized to other enterprises or other countries requires further examination. --- Conclusions Employees' both WFC and FWC are positively associated with their depressive symptoms. Organizational justice climate could weaken the effect of work-family conflict on depressive symptoms. The buffering effects of organizational justice climate in the association between work-family conflict and depressive symptoms only exist for employees with low family flexibility but not for those with high family flexibility. Interventions at individual, family, and organizational levels should be combined to reduce employees' work-family conflict and improve their mental health. ---

This study aims to examine how organizational and family factors protect employees from depressive symptoms induced by work-family conflict. With a cross-sectional design, a total of 2184 Chinese employees from 76 departments completed measures of work-family conflict, organizational justice, family flexibility, and depressive symptoms. The results showed that work-family conflict including work-to-family conflict and family-to-work conflict was positively associated with depressive symptoms. In cross-level analysis, organizational justice climate weakened the adverse effect of work-family conflict on depressive symptoms and the buffering effects of procedural and distributive justice climate in the association between work-family conflict and depressive symptoms depended on family flexibility. Specifically, compared with employees with high family flexibility, procedural and distributive justice climate had a stronger buffering effect for employees with low family flexibility. These results indicate that organization and family could compensate each other to mitigate the effect of work-family conflict on employees' depressive symptoms. Cultivating justice climate in organization and enhancing family flexibility might be an effective way to reduce employees' depressive symptoms.

Introduction Same-sex marriage in the United States was legalized on a state-by-state basis until the Supreme Court decision in June 2015 [Obergefell v Hodges [576 U.S. ___], which extended marriage equality to all 50 states . These changes in law have led to heightened interest in the impact of marriage legalization on individual, couple, and family well-being and on changes in sexual minority experiences of stigma. Stigma is generally defined as "co-occurrence of labeling, stereotyping, separation, status loss, and discrimination in a context in which power is exercised" , p. e1). Stigma directed toward sexual minorities involves social stigma regarding non-heterosexual identity, behavior, relationships or community . Stigma occurs at multiple levels: individual , interpersonal , and structural . Structural stigma refers to societal-, institutional-, or culturallevel norms and policies that negatively affect opportunities, access, and well-being . Supportive or stigmatizing political and social climates manifest on a continuum, from distal manifestations to more proximal manifestations including workplaces, schools, healthcare, schools, religious congregations, and local residential communities . Cultural-level norms often manifest in stigmatizing interpersonal interactions or microaggressions, which are "behaviors and statements, often unconscious or unintentional, that communicate hostile or derogatory messages, particularly to members of targeted social groups" p. 488). Structural stigma has been identified as an under-researched cause of health inequities, including higher risk for negative health outcomes among sexual minorities compared to heterosexuals . An example of structural sexual stigma is the denial of the right to marry, and the psychological, social, and practical benefits associated with marriage . Structural stigma in the form of state-level bans against same-sex marriage, and negative messages during public debates about same-sex marriage legalization, have been associated with significantly increased psychological distress and other negative health outcomes, such as alcohol use disorders and lower self-reported well-being among sexual minorities. Conversely, state-level legalization and social approval of same-sex marriage are associated with positive impacts on sexual minority psychological health, including lower depression symptoms , less identity concealment , improved physical health , and reduced suicide attempts among sexual minority high school students . Same-sex married couples residing in states in which marriage is legal have reported lower levels of identity concealment, greater acceptance of LGBTQ identity, and less vigilance and isolation . For same-sex couples, marriage legalization is often associated with a sense of relationship recognition and social inclusion, high levels of partner support, and perceptions of romantic, financial and legal security . Legalization of same-sex marriage may be associated with improvements in family members' and friends' perceptions and treatment of same-sex romantic relationships . However, negative family messages, ambivalent responses, or "don't ask, don't tell" family norms may be amplified in the context of marriage legalization or a couple's decision to marry , and at least one study did not find support for the hypothesis that residing in a state with marriage legalization increased family and sexualidentity specific support . Reductions in structural stigma, such as legalization of same-sex marriage, may influence sexual minorities' experiences of stigma and stress on multiple levels: individual, dyadic , interpersonal , and institutional . At the political/cultural level, changes in law recognizing the civil rights of sexual minorities appear to influence perceptions of social norms, which, in turn, may help reduce heterosexist attitudes and increase support for samesex relationships . For example, protections against discrimination in employment based on sexual or gender identity vary across states and local jurisdictions in the U.S. , and are associated with reports of less discrimination, less concealment of LGBTQ identities, and better health and well-being outcomes among LGBTQ individuals . A majority of studies on marriage legalization focus on the impact on individuals, couples and family relationships; however, few studies address the perceived impact of same-sex marriage legalization on interpersonal relationships within broader community contexts. Notable exceptions include research by Lannutti ). Lannutti conducted a qualitative study with 57 same-sex couples in which she assessed the impact of amendments prohibiting same-sex marriage on interactions with extended social network members, including work colleagues and casual friends. In that study, participants described coming out to people in their social network, receiving social support , experiencing solidarity , and, in some cases, encountering disconfirmation ). In a more recent study, Lanutti examined how same-sex marriage legalization impacted relationships with social network members among 27 committed same-sex couples who did not marry. The unmarried couples, interviewed after same-sex marriage was legalized in all U.S. states, described two challenges in their relationships with social network members: reduced support of their relationships, and perception that they were less committed to their partners because they chose not to marry. Most studies focusing on perceptions of same-sex marriage legalization were conducted prior to the Supreme Court decision legalizing marriage equality nationwide. Although sexual minority women and men may differ in their perceptions of social acceptance and support , few studies focus specifically on SMW. In those that do, even fewer include racially/ethnically diverse samples . Furthermore, a majority of studies about the impact of same-sex marriage legalization focus on married couples, and few studies include SMW who not married. Lannutti ) notes that legalization of same-sex marriage has profoundly impacted the social, cultural, and legal experiences and opportunities of sexual minorities-whether married or unmarried. Consequently, further investigation of the perceptions and experiences of SMW of different relationship statuses in the context of national legalization of same-sex marriage is warranted. Extended social networks and local community contexts play an important role for SMW in providing social support, creating a sense of normalization and belonging, as well as buffering stigma and minority stress. Although same-sex marriage is now legal in the U.S., ongoing political debates and social disagreements continue to impact the relational lives of same-sex couples and sexual minorities, including interpersonal extended social networks and in local community contexts ). Extended social networks include casual friends, neighbors, work colleagues, and others who are not close friends or family members . Local community contexts include, for example, workplaces, schools, healthcare settings, religious congregations, and local residential communities . The current study is part of a larger mixed methods research project designed to describe the perceived impact of same-sex marriage legalization and other political events on the health and well-being of SMW. The primary aim of the larger study was to explore the impact of marriage legalization on sexual minority women at individual, interpersonal, community, and institutional levels. Results from the larger study, including the impact of same-sex marriage legalization on interpersonal relationships with family members, are reported elsewhere {Riggle, 2017 #1646}. The current study draws on data from qualitative interviews with 20 SMW from 15 different states in the U.S. who were single, dating, in committed relationships, or married, to explore the following research question: How do sexual minority women describe the impact of same-sex marriage legalization on their experiences and interactions with their extended social networks and local communities? --- Methods --- --- Procedures Participants were recruited through an announcement on LGBTQ listservs, Facebook groups , and other social media. The announcement provided a link to online screening questions for lesbian, bisexual, and queer-identified women, ages 18 and older, who were interested in sharing their thoughts and life experiences regarding recent changes in marriage laws and other policies. For the first round of interviews, nine volunteers were selected from 67 respondents who completed the screening questions; these volunteers disproportionately self-identified as White, married, and with postgraduate degrees. We obtained the remainder of the sample from a separate study that recruited participants to participate in an on-line survey. These participants were recruited by announcing a link to a survey on LGBTQ websites . At the end of the survey we invited participants to indicate whether they would be interested in volunteering for other studies . We used purposive sampling to select 11 participants from the 481 individuals who indicated interest in being contacted for other studies. Women were selected participants to ensure inclusion of those under-represented in the initial set of interviews, including women of color, women with lower educational attainment, and unmarried women. Four of the research team members conducted the interviews. Participants were emailed a consent form and the interviewer read the consent to participants before proceeding with interview. Participants were given a $30 Amazon e-gift card to thank them for their time. All study procedures were approved by the San José State University Institutional Review Board. Telephone interviews were conducted using a semi-structured interview guide. The interview covered a range of topics, including the perceived impact of marriage legalization on dating/romantic relationships, coming out, relationships with family, interactions and experiences in work and community contexts, as well as perceptions about the impact of other policies and political events. For example, participants were invited to describe their interactions and experiences within work contexts and their perceptions of how marriage legalization impacted interactions at work . Parallel questions were asked about participants' social circles and community groups, with prompts regarding interactions with neighbors, church, schools, community groups, and friends. Responses to other interview questions were included in the current analysis only if they pertained directly to experiences with extended social networks or experiences in institutional and community contexts. --- Analysis Interviews were transcribed verbatim by a paid, off-site transcription service. An inductive thematic analysis was conducted using the narrative responses to identify patterned responses or meanings associated with the research question. Four of the research team members who conducted the interviews conducted the primary analysis. First, two coders divided and independently coded the first nine interviews by reading each participant's responses and summarizing meaning in segments of data and writing memos about potential patterns and themes. More than 57 codes were collated and sorted into 10 potential thematic categories. Provisional codes and emerging categories were reviewed between the primary coding team , revised for consistency, and condensed further to create reach consensus on a provisional list of candidate themes and subthemes. Differences in categories and provisional themes were discussed between coders, with review by the fourth author, until agreement was achieved. The coders then reread and re-coded the responses to ensure consistency in emerging categories and to verify whether meanings were adequately represented by the themes. The initial coding scheme, including initial themes and subthemes, were applied to the next 12 interviews, and coders continued to review and refine themes and sub-themes in relation to the full data set. As described by Braun and Clarke , this iterative process allowed the researchers to 1) identify whether the themes "work" in relation to the full data set, and 2) refine or add themes/sub-themes themes that may have been missed in earlier stages of coding in order to ensure all data relevant to the research questions could be organized in a final set of themes and sub-themes. Themes were finalized and consensus was reached on their definitions and description for presentation in the results. Researchers used three strategies to ensure trustworthiness of data analysis in qualitative research . First, authors met regularly throughout the analysis to review similarities and differences in interpretation and reflect on ways as individual biases, values, and experiences that may have influenced analysis. Second, the authors employed use of an audit trail to log changes to the coding scheme, definitions of codes, and to review analytic decisions. To conduct a final check on the stability and trustworthiness of the data, the findings were examined and verified by the last author who had not previously participated in data analytic activities. --- Results Sexual minority women described the impact of same-sex marriage legalization across three broad thematic areas: impact on interpersonal interactions in the workplace; impacts on social interactions in extended social networks; and impacts on community contexts and queer communities. In each of the categories, sub-themes emerged that reflected perceptions of marriage legalization as as positive or as negative/neutral. Primary themes and sub-themes in each category are summarized in Table 2. --- Perceived Impact on Interactions in the Workplace Participants described two areas of positive impact of national marriage legalization on their work lives: feeling safer to come out at work and experiencing more tolerance and more frequent, positive conversations with co-workers about dating and romantic relationships. Participants also identified workplace concerns that were either unchanged or amplified by marriage legalization: experiencing continued or increased LGBTQ-related challenges at work and lack of workplace protections for LGBTQ people. Feeling safer to be visible and "out" at work.-Several participants reported feeling safer and more confident about disclosing their sexual orientation at work following national same-sex marriage legalization. Married participants, in particular, noted feeling more comfortable coming out since marriage equality. For example, a recently married woman explained how marriage legalization changed her assessment of safety noting, "It depends on the calculation for risks in a situation, but yeah, I mean in terms of a work environment, I think I've become a lot more comfortable, or mentioning my wife's name, or using pronouns, whereas prior to the decision I didn't." . Another participant who noted, "I was always very closeted at work; I just never felt comfortable" went on to explain how marriage legalization impacted her willingness to be visible about her same-sex marriage: And then it [marriage legalization] was just there… [Same-sex marriage] was just very normal, this is what people do. So I appreciated [marriage legalization] on that level. I find in my day-to-day interaction, when people ask if I'm married, I say, "Yes." Like at work --I find that people talk very openly about their spouses and I find, for me, I was always little closeted, or very closeted, whereas now it's just like I feel emboldened to just be out. . Some unmarried participants also reported being less afraid to talk about their identity with co-workers and those encountered at their place of employment. One participant who is employed by a school stated, "It's more of that same feeling of it feels a little bit safer to come out. Just the idea that it's a little bit less out there in terms of being deviant or weird or crazy" . Describing the way that same-sex marriage legalization influenced her expectations for acceptance, another participant offered, I feel like talking about my sexuality and my gender expression is something that should generally be accepted by people. That I should not feel afraid to be able to talk about it at work and stuff because I mean, we have marriage equality and that's something that naturally needs to be accepted. --- Experiencing more tolerance and positive conversations at work.-Some participants described their co-workers as being more likely to express their support of LGBTQ people. For example, one participant reported changes in workplace communication norms, "I think there has also been a shift towards, at least, tolerance being the norm in a workplace…. I think now that [same-sex marriage] is legally recognized, there's some understanding that you can't be a jerk" . One woman in a committed relationship stated of her co-workers, I do have people ask me a little more about [my partner]… I've actually had the head of the practice address as her as my wife, once or twice. I'm like, "Thank you for mentioning it like that. We're not actually married, but we would be if we could financially do it right now, but we're not." That was nice to have been addressed in that way, even though we can't yet. Participants frequently described positive interactions that were directly related to the 2015 Supreme court decision, which affirmed or amplified their perception of support in their work environments. Several participants were particularly moved by interactions with supportive co-workers during or immediately after the decision. For example, Participant 12 described finding out about the Supreme Court decision at work, where a co-worker hugged her and said, "Dude, you're going to be able to get married now!" and her manager called from out of the country to congratulate her. She contrasted the enthusiastic response of coworkers to the absence of response from her family, noting, "I didn't hear any, 'Hey, congratulations, Hey, when's the wedding?" from family. Facing continued LGBTQ-related challenges at work.-While many participants reported positive impacts of same-sex marriage legalization on interpersonal interactions in the workplace, several described no impact, or continuing concerns about, and experiences of, stigma in the workplace. Continued LGBTQ-related challenges at work included maintaining or increasing vigilance regarding potential stigmatizing reactions from coworkers, or continuing to feel unsafe about visibility despite marriage equality. Several individuals expressed that they continue to be strategic about assessing potential heterosexism or concealing their identity at work in relation to co-workers who they perceived as opposing same-sex marriage implicitly or explicitly. For example, one participant explained that marriage legalization made her feel both more and less secure at work, primarily in relation to her ability to assess co-worker hostility. "I think that it's easier to read people, to know whether they'll be respecting or not, because people are homophobic then. They either come out and say it if they're really homophobic, or they are silent and tolerate." She goes on to explain that the "marriage decision really has polarized from opinion to give people some really 'charming', crystallized talking points for practice," such as co-workers at her last place of work who changed and became "more reactive about it….I would not say they were ever pro same-sex marriage, but they were not quite a vocally opposed and nasty as I see them get on Facebook now." Similarly, another participant explained, It's like if I'm disclosing to someone who I predict will be neutral to positive towards coming out, I'm more likely to tell them and less likely to feel anxious or have any concern about it. For people I suspect would be opposed to [marriage legalization], I'm probably less likely to tell them because I know people who are opposed to it are upset about the ruling and a lot of those people feel kind of under siege and like they're losing their America and that all these ideas are being forced on them. Other participants noted that marriage legalization did not impact the overall climate in their work contexts and reported concealing their identities and moderating discussions because of persistent fears of homophobia from co-workers and clients/customers. For example, one woman commented, "Corporate America is still not a place where I feel safe discussing gender, gender equality, gender politics, marriage equality -anything queer." . Participant 3, who works in a state psychiatric hospital described being comfortable in being open with other clinicians but reported seeing and hearing homophobic behaviors and remarks from other staff and stated that "With the broader work population, I am more reserved about it [sexual identity]; there's kind of a selection process there…I'm deliberate in who I disclose that to." A government employee who works directly with the public described, "I don't think it [my sexual identity] would be an issue with my boss, but I would be worried about the people that we help.…. I would be concerned that the more conservative [people] of my town doing something about it, especially working for the government" . She concluded, "I think that my identity and my gender identity just has to be something that I keep to myself within that sector." Having concerns about lack of legal protections against workplace discrimination.-Many participants commented that the absence of consistent laws or policies that protect sexual and gender minorities against employment discrimination was made more obvious by national marriage equality. Some pointed out lack of employment protections were particularly ominous in the context of marriage legalization, as they could negatively impact LGBTQ people entering same-sex marriages. For example, one participant, from a state with discrimination protections in place noted, "The people in-I don't know how many states it is, but there are a number of states-can still be fired based on, like, their sexual orientation. That I think is ridiculous" . Another participant described the employment risks faced by many same-sex couples who were married: "We saw that in couples who got married and came home and put their spouses picture on their desk and they were fired, because that was still legal-there is no job protection" . --- Perceived Impact on Interactions in Extended Social Networks and Local Community Many participants perceived a shift in norms in the local social climate since marriage equality and participants often noted they began having more frequent and positive conversations with their extended social networks about LGBTQ issues. At the same time, many reported that marriage opponents became more outspoken about LGBTQ issues within their social circles or that they experienced experiencing continued discrimination and stigma despite policy shifts. Perceiving a positive shift in norms for social interactions.-Participants frequently reflected on the associations between marriage legalization and the social norms that guide interpersonal interactions. For example, Participant 1 explained that marriage legalization influences daily interactions, "because whether or not any particular person is against something like that [same-sex marriage], it doesn't matter, this is the law, you have to become tolerant, you have to become accepting." She concludes, "I think having something as powerful as our federal government recognizing it [marriage legalization] as, 'this is our law -this is what our nation stands for and what we are going to expect to see,' is progress" . Other participants echoed the observation that heterosexist views were no longer aligned with current laws. This resulted in a sense that the onus for dealing with stigma was shifting away from sexual minorities to those who hold heterosexist views and empowered participants to be more vocal in defending their identities and relationships in everyday interactions. For example, one participant noted, "Because I had that backup [of same-sex marriage legalization], I could say, 'Well, I'm legally married, you know, if you don't approve, that's basically your problem'" . Similarly, another respondent reported that the same-sex marriage decision allowed her to be authentic and demand respect in her interactions with others, describing her stance as follows: 'You know what? No, I'm not continuing to lie, or to prevaricate, or to hide the truth, because this is who I am. This is my marriage. This is my relationship. It is legally sanctioned. You can learn.'" . Noticing an increase in positive conversations about LGBTQ issues.-A few participants described positive conversations and interactions related to marriage legalization as helping to transform acquaintances into friendships, such as one participant who observed: "I think it [marriage legalization] has made it easier to open up to certain individuals and make way for ongoing relationships that become friendships, I'm thinking of neighbors in particular" . In addition, some participants pointed out that samesex marriage legalization heightened awareness and support among people in their communities and social networks. For example, one participant explained there was "jubilation" among people "who support us, and our co-workers and everything." The same participant pointed out that discussions about same-sex marriage increased awareness among people who were generally supportive, but who had not yet fully grasped the significance of the Supreme Court decision. She observed, It was interesting because we got reactions from some people who were like, "Oh, this is a big deal for you, didn't you have marriage already?" There is such a misunderstanding among many people in the community that--I mean we got it quite frequently, the comment of, "Oh, I thought you had it [marriage legalization] already, you didn't have it all over the place?" Noticing an increase in expressions of "hateful thoughts and opinions."-Many participants reported noticing marriage opponents in their lives became more outspoken about LGBTQ issues. For one participant observed, "even though at a federal level it [marriage legalization] might be OK, there's always challenges that you can encounter in your own neighborhood," adding "it's given people a license to be more vocal with their hateful thoughts and their opinions about what LGBTQ people are like" . Some participants were specific in describing increased hostile comments in interactions with people in local communities, partly attributed to backlash against marriage legalization, such as Participant 13 who perceived an increase in negative interactions at a local Catholic primary school where her daughter was enrolled after "three decent years there." She reflected, "I think what we've learned is the school is more predominantly conservative, so it [marriage legalization] was more a rallying for those folks to be more upset about the way the country was moving." Some participants noted that although legalization of same-sex marriage made them feel safer and more open, they still lived in fear due to reactions from people in their local communities. This was typified by one woman, who stated, "I'd say that the marriage laws definitely allowed me to be a little bit more open a little bit this year, but I think there is still that fear in there, that hesitation" . Other participants shared they did not feel safe in their local neighborhoods: "I don't feel safe out there. I really don't. Even in my own, my own area, you know, where I should feel comfortable, I still kind of don't" . A few participants in relationships noted that marriage legalization increased the likelihood that disapproving people in the local community will recognize them as a couple. For example, Participant 11, illustrated this dynamic in the following story: So I think when they see us together, they sort of put two and two together. And we were out shopping recently and I got what I am almost positive was a disapproving look from this one guy that sort of looked at us long enough to make me a little bit uncomfortable. So I do think that one of the downsides, probably, to be more visible just in general cultural now is that people that might not have suspected we were a couple before now do and it's--not that that's necessarily a bad thing in most cases, but for those people that are disapproving, that do have a problem with it, or, you know, worst case scenario, might want to do harm, we're a little more obvious now in that sense. Experiencing continued discrimination and stigma despite marriage legalization.-Some participants reported experiences of discrimination and unequal treatment after the legal change took effect. For example, one woman discussed her experience of discrimination while seeking changes in her and her partner's legal documents after getting married. She stated, "We had this whole conversation about whether they would accept my same-sex marriage license. I'm like, 'The federal government has recognized that my name has changed. Really you're going to disagree with the IRS?'" . An African-American participant reflected on continued discrimination more broadly, pointing out that changes in law do not necessarily impact the attitudes and behaviors of people in local communities: "As with the Civil Rights, changing the law doesn't necessarily truly shift the cultural landscape and there are still local policies and fights to be had in terms of really moving forward." She pointed out that despite Civil Rights Acts that mandated "the end of the segregated waiting rooms and buses, [these laws] did not make it end in the old Confederacy in the South." She described marriage legalization "a good place to start" adding, "you've changed the law [marriage legalization] but you haven't changed hearts and minds, or made people see your humanity based on that law" . Other participants emphasized how the change in laws did not lead to changes in her interactions with people in local communities that were meaningful to them, such as religious communities. This dynamic was illustrated by one participant who described attempting to use the change in marriage legalization as an opportunity to promote greater acceptance among leaders in her conservative Christian religious community: I'd been in it [the religious community] long enough to know what they accept and what they don't accept. And so, now I'm just trying to let them know how I feel about it [lesbian identity] and trying to see if there's some kind of way we can make it so it works for me and works for them as well. But, so far, I'm losing . Similarly, another participant described rejection from her Muslim community during a state-level marriage legalization campaign and after her subsequent choice to marry her same-sex partner in 2014 . She explains, "I was in a pretty conservative Muslim community at the time, definitely not pro-marriage equality --actually anti --like they were collecting signatures…to defeat the proposal." After marriage legalization passed in her state she described feeling "completely joyful" and "vindicated." Legal marriage made her sexual identity visible in her community and "all hell broke loose." "I don't think I quite anticipated the level of rejection from the [religious] community or people, like, close acquaintances. She ultimately distanced herself from the religious community, noting "I no longer felt safe --not, like, physically safe, but I no longer felt emotionally or, you know, psychologically, spiritually safe in that community" . --- Perceived Impact on Community Climate and Queer Communities Participants described positive impacts of marriage legalization on the local community climate and on LGBTQ communities in two ways: 1) feeling greater social acceptance and feeling "normalized," and 2) having a sense of equality and expectation of equal treatment. Although these themes emerged for participants across relationship status and age, differences in the narratives of participants emerged in each of these themes. Older participants often provided long and detailed life-course narratives to explain the impact of marriage legalization as a symbol of greater acceptance and normalization. Detailed descriptions of being treated as "equal" to heterosexual couples emerged as particularly salient to married participants. At the same time, many participants expressed concern that marriage legalization may have limited, or even negative, impacts on LGBTQ communities in two areas: 1) concerns about marriage as an institution and assimilation into heteronormative society, and 2) concerns about the mainstream LGBTQ movement's focus on marriage over other issues impacting the community. Experiencing social acceptance and feeling "normalized."-Many participants reported feeling more normalized in their identity as sexual minority individuals after marriage was legalized nationally, linking this change to their increased feelings of social acceptance. For example, one participant described the psychological effects of this change: "It just, for me it's just very refreshing. Like it's almost like this, marriage equality, helped normalize my own queerness" . Another stated that the change in marriage law and perceived increase in LGBTQ normalization has "given me better self-esteem" . Another participant conveyed her sense of feeling more "legitimate" in her public presentation in broader community contexts and social media: I think it's that idea that, maybe it's just about me, maybe it's about my confidence, having the legal backing to support the validity of my sexual orientation. I'm a lot more outspoken about it [sexual orientation] on social media and within my life. It feels more legitimized, so I don't have to play the game of staying in the closet or hiding, or having this don't ask, don't tell because it makes other people uncomfortable. Several participants, particularly those in their 40's or older, described the impact of marriage legalization from a life-course perspective. For example, these participants commented that they never thought marriage legalization would occur in their lifetime, that marriage legalization was "a long time coming" and that marriage would never be a choice for them. Participant 14 explained: Well… I mean it [marriage legalization] was life-altering for me. I grew up that being gay was something that you just didn't tell anybody. In fact for most of my life I just thought I was an anomaly. So marriage was never something that was on my radar, it was just never something I thought was for me… And so to have the Supreme Court of the United States come out and say, "These people can get married. There is nothing wrong, they should not be--they should not have rights withheld from them." It just--the validation was, and through the whole community, there was just such happiness and freedom. And you feel like you can live your life without having this constant thing that distracts you. And not just marriage, but being gay. Having a sense of equality and expectation of equal treatment.-Participants who were dating or in romantic relationships with other women often reported feeling their relationships were perceived as more valid or more "equivalent" to heterosexual romantic relationships by extended social networks and in local community contexts. For example, one woman described the way shifts in others' views of her relationship affected her: "I do think there's just something very empowering or validating in that my relationship is not seen as other" . Another single participant elaborated on how marriage legalization helped frame her dating experiences as equivalent to heterosexual acquaintances and co-workers: Now I feel much more confident and much more able to say, "yeah, I'm dating and I'm looking to [a] long-term goal [to] get married." They know what that means. I don't feel the anxiety that causes me to then go on this big tangent about what that means and why that's okay and why it's not that different from how they're dating. It just feels a lot more concise, and I feel a lot more confident in being able to just say that and own that. Although both single and married participants described feeling a greater sense of equality, married participants often elaborated on specific ways same-sex marriage legalization impacted their expectation of equal treatment and their sense of safety. One participant tied marriage legalization to equalizing her social status: "It makes me feel like I'm finally on an equal footing with other people in society. Because really and truly, you know, we weren't before. We were essentially treated as second class citizens" . Some participants stressed a sense of relief related to safety. For example, one participant , who was married in her state prior to the 2015 decision and who traveled frequently for work, was previously concerned about "piecemeal state policies… if something were to happen…or if someone was injured." She discussed the impact of having consistency in national policy on her and her wife's sense of safety: I think that it enabled us to really feel like we're legally married no matter where we're traveling to. We're everywhere, we're wives, we're legally protected… We may have to carry the marriage certificate, we may have to push people who don't really accept it or know about it but we've got the law on our side, so we're safer. Feeling concerned about assimilation and reinforcing heterosexual norms.-Some participants reported concerns about whether the focus on gaining national marriage legalization would further assimilation of LGBTQ communities into mainstream heteronormative society and undermine political critiques of marriage as an institution. For example, one woman stated, "I think that marriage is an antiquated, possession-based sort of thing, where women were not treated as humans. So historically, I don't think marriage is an awesome thing in itself…I wonder sometimes if we're being homogenized into, if it's a bad thing that we're being kind of homogenized into the larger, or majority, community." Although the majority of participants described positive impacts of same-sex marriage legalization on their personal lives, many participants concurrently reported experiencing personal and political ambivalence or disapproval of the institution of marriage, which is typified by the following quote: "I'm appreciative and I'm happy that we have this legal recognition across the country, but at the same time, kind of politically and in many other ways, I wish that we didn't have to be a part of something that was meant for so long to keep us out." Additionally, a few of the participants who were married reported feeling conflicted about the act of getting married and what it meant about them as LGBTQ people: "I feel like now I've joined something that I for so long have had a problem with or this institution that I have spoken so much in opposition to" . Expressing concerns about social movement priorities.-Participants also discussed concerns about the LGBTQ movement's strategic decision to focus on legalizing marriage as a movement priority. For example, a few participants pointed out ways the focus and framing of marriage equality advocacy rendered people of color invisible or minimized the contributions of queer people of color in social change. For example, Participant 20 talked about how the framing of marriage equality emphasized images of young, white gay and lesbian couples as the "poster child" of the movement, comparing this to both the "invisibility of queer folks in civil rights organizing" and invisibility of people of color in earlier battles around "Don't Ask, Don't Tell." For example, she commented on a similar dynamic where "a black gay drag queen had been locked in a battle with the military because they wanted to discharge him when they found out he was gay." She noted, "there was no place for him in that push around gays in the military because he was not a poster child." She called for "an integrated approach of seeking justice…because there has to be room for all of us on the bus," and also stated, "we as human beings don't tend to subdivide; I refuse to make a choice between my skin, my ovaries, my wallet or the love of my wife." Many participants commented that marriage legalization was "a good start," but that it was not enough. Some participants elaborated on the need for other protections against discrimination and other areas of concern, including concerns that intersect with race, gender presentation, and other identities. For example, Participant 2 , commented "I feel like if there were laws that were antidiscriminatory and anti-harassment…it would help change the climate of things, but that's not what we have. Participant 2 went on to say "also the trans women of color that are being murdered, that makes me feel more scared for myself, even though I'm not trans, it's sort of in my pool, so I have to be careful." It was notable that many participants, particularly participants who were interviewed after the 2016 presidential election expressed concern about community climate and emerging policies designed to impede sexual or gender minority rights. A few participants expressed the concern that "we won't be able to get married; that he [the president] will block that and because of his orders and that's it for us" . One participant even moved up her wedding date because "they can't take it away once we've done it" . Similarly, Participant 9 commented on the negative impact of the election on the local social climate by explaining "we've seen it on the national news and here a little bit on the local level as well" that the election outcome has empowered hostile people "to be louder." She elaborated, with examples: We had a couple incidents here locally of yahoos in pickup trucks, driving through what had been historically gay neighborhoods, you know, yelling "Trump won" or "fuck you, Trump won" or whatever. Once or twice, and they were reported. Duly reported, but those were the ones that we know about. I don't know how many things have happened that we don't know about. --- Discussion The current study, conducted after the 2015 Supreme Court decision extended marriage legalization to all states, examined the perceived impact of legalization of same-sex marriage on SMW's interactions within their extended social networks and local communities. Inductive analysis of responses revealed impacts in three broad thematic areas: workplace dynamics and interpersonal interactions in the workplace, social interactions in extended social networks and local communities, and perceived impact on local community climates and LGBTQ communities. In each of the categories, sub-themes emerged that reflected positive or negative/neutral perspectives about the impact of same-sex marriage legalization on stigma-related concerns and experiences. Although some findings were consistent with prior research focused on state-level same-sex marriage legalization, our study revealed new themes describing the impact on SMW. For example, one prominent theme involved descriptions of changes in social norms shifting the discomfort in stigmatizing social interactions from those who identify as sexual minorities to those who hold negative views of sexual minorities and same-sex relationships. Since the current study was conducted after the 2015 Supreme Court decision extended legalization of same-sex marriage across all states, it is possible that these emerging themes reflect shifts in social norms about sexual minorities and same-sex relationships. It was notable that participants across discrete relationship statuses generally described similar feelings of improved social acceptance and an increased sense of being treated as equal to heterosexuals. These findings are consistent with Riggle and colleagues recent study , in which participants described improved social support and acceptance as a result of same-sex marriage legalization. The theme of being treated equally was particularly salient to married participants in the current study who expressed appreciation, relief, and an increased sense of safety in having the ability to assert and defend their rights both in local communities and when traveling across state lines. It was also notable in the current study that some participants, particularly participants over 40, described marriage legalization as a significant milestone in feeling "normal" and accepted as part of their overall life narrative. Future research is needed to explore the importance of marriage legalization as a phenomena that may be experienced differently by age-cohorts and that should be viewed from a life-course perspective. One of the overarching themes was conflicting perceptions about whether same-sex marriage legalization would or would not improve stigmatizing interactions and experiences in workplace and community contexts. Many participants described feeling hopeful that marriage legalization was a sign of increased LGBTQ acceptance and would continue to advance acceptance. At the same time, many noted that marriage legalization did not necessarily improve daily interactions or decrease experiences of microagressions, such as participants who described hearing negative comments at work or feeling rejection from members of their local neighborhood, religious, or school communities. Sexual minorities are often exposed to microaggressions in interpersonal interactions, including microassaults , microinsults , and microinvalidations . Microaggressions that have been identified as particularly salient to LGBTQ couples and families involve others questioning the legitimacy of their family relationships , framing LGBT families as conflicting with family values, and pathologizing families in relation to lack of traditional gender roles . Previous research has found that experiencing microaggressions in the social environment appears to have a negative impact on sexual minorities, even when controlling for supportive policies such as marriage legalization . Results of the current study similarly indicate that many participants continued to experience microaggressions post-marriage legalization. This is concerning, particularly given research documenting the negative impact of sexual stigma on health . Data for the current study were collected prior to and after the 2016 presidential election. The changing political and social climate appeared to impact respondent descriptions of comfort and safety in their extended social networks and communities, as well as conversations and other interactions perceived to be explicitly anti-LGBTQ. Many participants pointed to national political events and policy debates as factors that fostered continuing or increasing levels of stigma in their interactions at work or in their community, and these concerns were amplified in the narratives of post-election interviewees. Increased concerns about stigmatizing discourse and emboldening of hostility related to sexual minority status, race, and immigration status in the aftermath of the 2016 presidential election have been documented in other studies including SMW and gender non-confirming individuals . A few participants in the post-election sample described concerns that marriage legalization might be rescinded and some specifically stated that they moved up their wedding dates as a result of these concerns. This finding has been echoed in other research, which revealed that fear of losing rights and benefits of legalized same-sex marriage was one of four key motivations for same-sex couples who married shortly after the 2016 presidential election . Lannutti also found that participants perceived their marriages in the context of their immediate and extended social networks as both a perceived threat among heterosexuals and as a rallying point for resistance in response to the 2016 election . Future research is needed to document the impact, over time, of same-sex marriage legalization and other policies on sexual and gender minority health and wellbeing. Evidence from other countries suggests that sexual stigma and negative health impacts may persist even in the context of same-sex marriage legalization. For example, a recent study conducted in the Netherlands found that despite 20 years of marriage rights, sexual minority adolescents were still at greater risk for substance use and lower levels of well-being, which was attributed in part to continued stigma on individual, interpersonal and societal levels . The persistence of stigma in everyday interactions and in the larger social climate remain important areas for future research and intervention. It was notable that participants in the current study frequently pointed to the lack of consistency in other legal protections against discrimination as undermining the positive impact of same-sex marriage legalization. Specifically, participants routinely described their work environments in relation to how accepting, "safe," or rejecting the climate or coworkers appeared to be. Many explicitly voiced concerns about how the visibility inherent in being legally married might increase risk for discrimination at work, for themselves or for others, in the absence of broader protections against discrimination. This finding is consistent with research documenting continued barriers to equality, including the lack of protection again employment discrimination in state non-discrimination laws for sexual minorities or transgender persons , as well as the surge in "religious freedom" laws allowing refusal of health or other public services to LGBTQ people , 2015). More broadly, participants noted that same-sex marriage legalization alone did not ensure full inclusivity or safety in their communities. For example, some described their inability to protect themselves from exposure to negative comments and conversations in contexts where policies and social norms appeared to sanction discrimination. Consistent with this finding, Riggle, Rostosky and Horne found that lesbian, gay, and bisexual individuals living in states and cities with nondiscrimination policies inclusive of sexual orientation perceived their environments to be more positive, experienced less minority stress, and described fewer instances of engaging in, or overhearing, negative conversations than those in regions without protections. Future research on the impact of marriage legalization should integrate consideration of the impact of local policy climate, including the presence or absence of inclusive anti-discrimination laws. --- Limitations and Conclusions This study was novel in its identification of both improvements and unexpected challenges for SMW following national same-sex marriage legalization. Nevertheless, readers should also consider the limitations of the study. First, the sample included only 20 participants. Additionally, the sample over-represented participants with college and post-graduate education levels. The sample included only SMW; interpersonal interactions and experiences in local and LGBTQ communities may differ for sexual minority women and men. Additional research is needed to investigate the impact of changes in the social and policy climate and possible differences by sex. This study contributes to an emerging literature on the broader impacts of same-sex marriage legalization, particularly because we included single and unmarried women. Additional research is needed to determine the full, long-term impacts of marriage equality on SMW, especially within sub-groups that are more marginalized and understudied. Although the impacts of same-sex marriage legalization were generally described as directly or indirectly improving the lives of women in work and community contexts, many participants also reported stressors that had not changed or had worsened, or reported concerns that other issues facing the LGBTQ community, such as people of color, were not given sufficient attention. These findings underscore the importance of interventions to reduce stigma, and that community and contexts may be particularly apt settings for interventions. Further, our findings highlight the importance of workplace non-discrimination policies, as well as local and national non-discrimination laws, that include sexual and gender minorities. However, even when there are protective policies and laws in place, such as marriage equality, SMW may still be negatively impacted by complex and persistent stigmatizing interactions. ---

The extension of marriage rights to same-sex couples in the United States provides an opportunity to examine how legalization of same-sex marriage has impacted the experiences of sexual minority women (SMW) in interactions within their extended social networks and local communities. Interviews were conducted with 20 SMW ranging in age from 23 to 75, with varying relationship statuses, and in different regions of the U.S. Inductive thematic analysis of responses revealed both positive and negative/neutral impacts in three broad thematic areas: workplace dynamics and interpersonal interactions in the workplace, social interactions in extended social networks and local communities, and impacts on community climate and queer communities. Findings of the study underscore the importance of evaluating the impact of same-sex marriage legalization in the context of local social and political climates.

Introduction Obesity tends to develop early in life, with incidence peaking during early childhood. [1,2] The household is the most important context for wellbeing through early and middle childhood; [3] accordingly, expert recommendations identify the household as the most important context in which to prevent or reverse obesity in children. [4][5][6][7][8] Efforts to prevent obesity and to promote healthier weight among children with obesity emphasize family-focused strategies. [4,[8][9][10][11][12][13] However, these efforts generally are agnostic about who in the household matters and how household dynamics can enable or prevent unhealthy growth patterns. Many programs and studies focus on parents, but far fewer consider other co-residing individuals and their roles with respect to children's risk of obesity. Of these studies, many do not measure the range of household family contexts and their influence on childhood obesity simultaneously. [14][15][16] The literature on child health in the social sciences has identified multiple aspects related to household structure, including parents' marital status, children's biological relatedness to household decision-makers, and intra-household competition for resources, as critical to children's wellbeing, because these affect net resources, resource allocation, behavioral modeling, and childcare. Much of this research has been based, theoretically and empirically, in resource-poor contexts, where key relatives can prevent malnutriton by providing muchneeded food, or can allow children to attend school by paying school expenses or releasing children from household labor. [17][18][19][20] In this study, we add to the obesity literature theoretically informed, nuanced measures of household structure and apply these to data over nine years from the Early Childhood Longitudinal Study Kindergarten Class of 1998-99 , the largest nationally representative longitudinal study measuring child wellbeing and household characteristics from Kindergarten through eighth grade. We explore how the conceptulizations of houseold structure and child wellbeing largely developed in resources-poor settings apply to child growth in contexts in which additional calories and less exertion may not be beneficial. --- Household structure and child health Similarities in bodyweight within families have a genetic component, but behavioral and social factors also are likely to be important, and genetic predispositions work in concert with environmental exposures [3,[21][22][23]. Household structure, typically measured as co-residence with close relatives, relates to several components of child wellbeing, including education, health behaviors, mental and physical health, and growth [3,[24][25][26][27][28][29][30][31]. Such relationships likely exist because household structure shapes components of the home environment, including availability and distribution of resources, time allocation, norms and behaviors. Specifically with respect to child growth and the risks of obesity, household structure can affect food availability and eating patterns, levels of activity and inactivity, and rules and supervision, all of which may be linked to children's risks for obesity [8,32,33]. Contemporary families take many different forms. One aspect important for child wellbeing is the number of co-residing parents: about 65% of American children live with two married biological parents, and this percentage ranges from a low of 32% among African American children to a high of 84% among Asian American children [34]. Over half of children born in the 1990s spent some time in single-parent or step-parent living arrangements [35]. Studies of household structure and children's wellbeing have focused on the negative consequences of living with one parent, most commonly a single mother [14,30,35,36]. This discussion has centered on the limited economic resources and time to devote to children in these families and the absence or inadequacy of paternal role models and supervision [17,37,38]. In terms of obesity, children living with a single mother more often have been reported to be obese in elementary school than children living with two parents [30,36]. A second less studied component of household structure with respect to child obesity is the parents' relationship status. Studies from the US and elsewhere indicate that the children of married parents are healthier on a myriad of indicators, beginning with health and survival at birth [39,40]. Also in the US, youths with unmarried parents have had poorer educational outcomes and less health-promoting behaviors than youths living with married parents [35]. Marriage may proxy for the quality and duration of the parents' relationship, and may commit both partners to invest in children [28,41]. A third aspect of household structure, also understudied with respect to obesity, is the relatedness of co-residing parents to the child. Children living with stepparents are disadvantaged compared with children living with two biological parents [15,[41][42][43]. In the U.S., step-parents have tended to invest less in children than do biological parents: households that include stepchildren spend less on food: spending varies with the relatedness between mother and child, with less spent on adoptive than biological children, less on stepchildren than on adoptive children, and less on foster children than on stepchildren; children living with stepmothers are also less likely to have routine doctor and dentist visits, to have a health care provider, to wear seatbelts, and to live in a non-smoking home [28]. For many components of health, children living with a father and step-mother are no better off than those living only with a father [42,44,45]. Among half-siblings in the same household, those who were step-children to one parent had poorer outcomes in terms of education, health investments and social wellbeing compared to their half-siblings who were biologically related to their parents [15,28,41,44,46,47]. About 15% of American children live in a home with non-parent adult relatives, most often grandparents [48,49]. Children of racial and ethnic minority families are more likely to live with other relatives in addition to or in place of parents: 20%-24% of African Americans, Hispanics, and Asians households include extended family, compared with 9% of non-Hispanic White households [34]. Co-residence with more adults usually has been positively associated with child health because these adults can provide additional supervision and income, though the relatedness of the child to the adult may be relevant [19,27,[50][51][52]. In studies from around the world, children with a surviving nearby or co-resident grandmother are healthier in terms of several indicators, including survival and growth [19,40,[50][51][52][53]; such relationships were not found for grandfathers [54]. In the US, teenagers living with a single mother and a grandparent had schooling outcomes and health behaviors equal to or better than teenagers living with two parents [35]. The role of non-parent adults is complicated because it often is entangled with parents' relationship status and living arrangements [55]; still, related adults, especially grandparents, can often mitigate the negative outcomes that children living in non-intact families would otherwise experience [56]. In terms of nutrition and obesity risks, non-parental co-residing adults, especially grandmothers, often assist with childcare, supervision, and the preparation of meals. Literature suggests that children who live with grandparents are more likely to be overweight [57,58]. Grandparents encourage children to eat more, use food as an emotional tool, and favor heavy size in children [16]; mothers have reported pressure from grandmothers, who are concerned about children being too thin, to give children more food, [59]. Children living with grandparents also had poorer weight-related behavior [34,58,60]. Over 75% of American children live with siblings or other children [34]. The relationship between number of children in the household and their health is ambiguous because multiple children entail more competition for resources [44,61,62] but siblings, especially older siblings, also may promote health: in a review, 5 of 6 studies from around the world documented that having older siblings improved survival up to the age of 15 years [54]. In terms of obesity risks, siblings may provide opportunities to be physically active [25]; indeed, children with siblings may be obese less often than single children [36,62,63]. --- Implications of household structure in a calorie-surplus context Previous research has highlighted the ways in which household structure is associated with child wellbeing. Indeed, many of the benefits of household structure for children's wellbeing have been based in contexts of scarcity-where a single mother may not have the resources to provide sufficient food, clothing, or school fees to promote her child's health and education; where other adults providing supervision and modeling can facilitate school attendance or vaccination. But what resources are needed to prevent the emerging health problems associated with high energy consumption and inactivity, such as obesity and diabetes? The benefits of household-level investments in more calories and more sedentary time for children's health in resource-rich settings are less clear than they are in poorer settings: providing maximum nutrition and shielding from physical exertion may actually be detrimental. Observed lower per capita quantities of food in step-and adoptive families may promote healthier weight for children in the U.S. Biological parents and grandparents may be more permissive, buy junk food in response to children's pleas, not encourage walking commutes, and provide excessive indoor and screen-based games. If so, their children may experience excess weight gain. For obesity prevention and reversal, some family inputs, which in poorer settings would be important investments, for example larger quantities of high-calorie foods or more sedentary time than the local average, could actually lead to poorer outcomes. We hypothsize that: 1. Children living in households a) with two parents rather than one and b) with parents who are not biologically related experience lower risks of developing obesity during elementary school; 2. Children living in households with a) additional related or non-related adults or with b) a grandmother have higher risks of developing obesity during elementary school; 3. Children living in households with siblings have lower risks of developing obesity during elementary school than only children. The relevance of household structure can be assessed in the context of other forces that may be related to child growth. Child characteristics associated with growth patterns include gender, race/ethnicity and age [64][65][66][67]: Obesity risks are higher among Hispanic and non-Hispanic black children than among Non-Hispanic white children; these differences emerge early in life [68][69][70] and continue to grow into adolescence [1]. Low parental education has been correlated with higher rates of child obesity, both because education is associated with employment quality and consequently material and immaterial resources, and because education is associated with greater knowledge about health and nutrition [65,71,72]. These patterns endure across generations, as both parents' and grandparents' education is associated with childhood obesity [73]. Compared to households with mothers who do not work, those with working mothers tend to have higher levels of child obesity, as employment can reduce parents' availability to plan meals and play with children [65,[74][75][76]. Higher rates of obesity have been observed in the U.S. among poorer individuals in recent decades, and poverty may prevent families from providing nutritious food [65,67,71,77]. Children from low-income families are more likely to be obese, even after accounting for parents' BMI [78]. At age 5 years, children from the poorest quintiles of families had higher obesity prevalence than their peers: 13.8% and 16.5% among the 2 poorest quintiles vs. 7.4% in the wealthiest quintile; obesity prevalence was highest among children in the next-to-poorest quintile, reaching 25.8% by age 14 years [1]. Relevant community characteristics include characteristics of the school attended, urbanicity, and U.S. region of residence. Children who attend public schools have a greater likelihood of obesity than children who attend private schools [79]. There are regional differences in obesity rates in the U.S., with highest prevalence among children in the Southeast and lowest in the Mountain and Western states [80,81]. Childhood obesity rates differ between urban, suburban and rural areas, but these differences tend to be small and vary by age: younger rural children and older urban children are least often obese [81,82]. --- Data The Early Childhood Longitudinal Study, Kindergarten Class of 1998-99 is a study of children's early school experiences, developed by the National Center for Education Statistics and following a large cohort from Kindergarten to 8 th grade. Multistage probability sampling was used to select a nationally representative sample of kindergartners [83]. At each wave, measures included direct anthropometric, cognitive and academic assessments and detailed information on the home and school environments. Details on the data have been published elsewhere [84]. Height and weight were measured twice per wave by trained assessors: height in inches to the nearest 0.25 inch using a Shorr Board and weight in pounds using a digital scale [83,85]. This procedure is a major advantage over datasets that collect self-reported or parentreported anthropometric data, which have been shown to be systematically biased [82,86]. The baseline sample, with 21,260 kindergartners, average age 5.6 years, was collected in the Fall of 1998; subsequent waves were in the Spring of 1999,2000,2002,2004, and 2007 and a 30% sub-sample in the Fall of 1999. Children were retained in the sample if they fell behind or advanced ahead in grades. Most attrition resulted from random selection for non-sampling due to survey costs of children who moved to different schools before fifth grade [83]. With the use of survey weights, the longitudinal sample is representative of individuals who were in Kindergarten in 1998-99 or in 1 st grade in 1999-2000. --- Ethics statement This article is based on the secondary analysis of anonymized, de-identified public-use data files available to researchers via the Inter-University Consortium for Political and Social Research . Human participants were not directly involved in the research reported in this article; therefore, no institutional review board approval was sought. --- Methods --- Variables The outcome measures used were obesity at each data wave , incident obesity among those not obese at the last wave and change in BMI between waves. Obesity in children is more complex to define than in adults because increases in weight and changes in body proportions are part of growth and maturation. Therefore, z-scores or percentiles are typically used for cross-sectional analysis [87]; we constructed BMI z-scores based on weight, height, sex, and age, with reference to the age and sex-specific 2000 CDC Growth Reference with cutpoints for obesity at the 95 th percentile. For change over time, raw BMI is used because the variability of z-scores over time is lower for the heaviest children [88]. Household structure characteristics were defined at each survey wave in terms of number and relatedness of parents in the household ; parents' marital status ; co-resident grandmother , other co-residing adult relative , co-residing non-relative adult ; coresiding siblings . We controlled for child's sex , race/ethnicity and age ; household socioeconomic status ; household food-insecurity ; mother's employment ; type of school currently attended ; U.S. region ; and urbanicity . --- Analysis We used survey adjustments and attrition weights designated by the NCES for all descriptive and analytic methods. We began with descriptive examinations of the data at all waves, with a focus on indicators of body weight and household structure. We then used t-tests to compare characteristics in Kindergarten and eighth grade between children according to their weight status at the end of eighth grade. We used multivariate logistic regressions to identify, at each data wave, which characteristics were associated with obesity. In longitudinal analyses, we estimated associations between characteristics and circumstances in Kindergarten and subsequent weight status and incident obesity. By focusing on changes over time, we account for the cumulative nature of weight gain over time [86,90]. On the right-hand side are vectors of household structure, child characteristics and household social and economic characteristics, and community characteristics. We used lagged surveyadjusted regressions to estimate the association between household structure and subsequent changes in children's weight when children were in first, third, fifth, and eighth grade: linear regression with right-hand side variables at time t as predictors of weight change between time t and t+1, and logistic regression with right-hand side variables at time t as predictors of incident obesity between time t and t+1. --- Results Table 1 shows characteristics of children who attended Kindergarten in the U.S. in 1998 as they grew from Kindergarten through 8th grade. All numbers are rounded to the nearest 10, per NCES requirements. Children's BMI increased with each wave. The proportion of children who were above the cut-off for obesity was 12% in Kindergarten and increased over time, peaking at 22% in 5 th grade. In Kindergarten, 69% of children were living with both biological parents; this percentage decreased over time but remained at above half through 8 th grade. The percent of children living with a biological mother or biological father and step-parent increased over time, as did the percent of children with adoptive or foster parents . A substantial percentage of children lived with only one biological parent, typically the mother and rarely the father . Over 70% of children had a married mother or primary caregiver at all waves. Across time, about 9% of children lived with a grandmother. One in 10 Kindergartners lived with another adult relative and 4% lived with a non-related adult not designated as a parent; these household types increased substantially by eighth grade . Most children also lived with at least one sibling-83% in Kindergarten and increasing slightly thereafter. To understand characteristics that may be associated with excess weight gain during childhood, Table 2 shows the characteristics of Kindergarteners, distinguishing between those who would and would not be obese in 8 th grade. Children who were heavier in Kindergarten tended to remain heavy nine years later: among obese children in 8 th grade, 67% had been overweight or obese in Kindergarten. Children with obesity in 8 th grade more often were boys, children of Hispanic ethnicity, children from lower socioeconomic families, and living in urban areas. Children who were living with their mother and no father in Kindergarten more often were obese in 8 th grade, as were children co-residing with their grandmother or another relative; children whose mothers were married in Kindergarten and who had non-relative adults coresiding in Kindergarten were less likely to be obese nine years later. Table 3 shows the associations between household structure and children's obesity through elementary and middle school at each wave, accounting for other characteristics. The patterns indicate that children living with two biological parents do not have lower risks of obesity than children in other living arrangements: after accounting for other characteristics, children living with a biological mother or father and a step-parent had odds of obesity similar to or lower then children living with both biological parents or with just one parent. Children who were adopted had significantly lower odds of obesity in nearly all study waves. Children with a married primary caregiver had equal or lower odds of obesity; however, having accounted for the other household structure and socioeconomic characteristics, there is no additional association with parents' marital status. Children living with their grandmother had at least equal or higher odds of obesity as children not living with a grandmother. Children living with other relatives had equal or higher odds of obesity, while children living in households with non-relatives tended to have lower odds of obesity, though not significantly so. Children living with at least one sibling had lower odds of obesity than children without siblings. In Table 4, we use examine change in BMI over time. The table shows weight change between incremental ages; here, to summarize, we review the long-term patterns of BMI changes between children's entry into Kindergarten, at average age 5.6 years, and the end of eighth grade, at average age 14.1 years . Over this entire period, children living with two biological parents experienced similar BMI increases to children living with a biological parent and a step-parent, with adoptive parents, and with just one parent. Children co-residing with their grandmother gained more body mass than children not co-residing with a grandmother. Children co-residing with other relatives and with non-related adults gained less body mass. Children living with at least one sibling gained significantly less body mass than children without a sibling in the house. Other characteristics associated with high increases in body weight over the nine-year period were being in the lower socioeconomic quintile, living in the South or West U.S., and having a mother who was not working full time. Table 5 shows the risks of incident obesity among children not already obese at each data wave and over the entire period between Kindergarten entry and end of eighth grade. The patterns are consistent with those observed in BMI change, but notably there are no significant differences in long-term odds of incident obesity, that is, crossing over the 95 th percentile, associated with household structure. --- Discussion Previous studies have shown that household structure is associated with children's wellbeing, including health at birth, survival, growth, and education. Specifically, around the world, children whose parents are in married or long-term relationships, who are more closely related to co-residing adults, and who live with adults in addition to parents, tend to have better outcomes, primarily because of greater investments in resources such as food, vaccination, and school expenses [8,40,54]. The relationships between household structure and children's excess weight gain and risk of obesity requires a clearer understanding to better guide recommendations [8,63,91]. This relationship has grown in importance as obesity becomes increasingly prevalent worldwide and is especially relevant today in settings like the U.S., where absolute caloric scarcity is not a widespread challenge. Our findings indicate that one of the major health concerns for children today, obesity, may not be associated in the same way with household structure as are other aspects of child wellbeing. Adjusting for household structure more thoroughly than studies typically have, children living in households with two parents rather than one parent did not experience advantages in terms of lower weight gain or lower obesity risks during elementary and middle school. A prior study using the same dataset in fifth grade reported that children living with single mothers were more likely to be obese than children living with two parents [36,63]. We replicated these findings, but this relationship may be driven by differences between children living with two biological parents and those living with parents who were not their biological parents. Thus, we found no significant evidence of different growth patterns and obesity risks between children living with two parents or one. Adjusting for other characteristics of households, relatedness of the parents to the children was not associated with children's growth. Children living with a parent and a step-parent experienced similar or lower BMI gain and incident obesity to those living with a single parent and those living with adoptive parents. There is some indication that children living without their biological mother, including those living with adoptive parents or only with their biological father had lower risks of developing obesity. Previous studies have found that the mother is Table 3. Household characteristics and obesity between ages 5 and 14 years: Odds ratios from survey-adjusted logistic regression. ( the most important relative promoting child health and that children living without their mother were at significantly higher risk of mortality and other negative outcomes, at least in part because they receive fewer resources and less care [42,44]. Studies have shown that stepmothers do not substitute for mothers [15,43], and our findings corroborate these reports, but paradoxically indicate that living with a step-parent is not associated with worse outcomes in the case of obesity. One concern would be whether the absence of obesity is actually a negative outcome, in that it could indicate underweight, but we did not find this to be the case, as children living in step-families were not more often underweight than children living with both biological parents. Previous studies have highlighted the protective role of grandmothers in child wellbeing, but also have indicated that they may promote obesity. In this study, children living with a grandmother had more increases in BMI z-scores and were more likely to develop obesity than children not living with a grandmother. Living with siblings was associated with lower obesity risks and lower weight increases. Thus, sibling competition for resources does not lead to poorer outcomes in terms of obesity. Perhaps parents with multiple children provide more structured lifestyles for financial or organizational reasons [61], and these lifestyle differences are protective against excessive weight gain [36,92]. It may also be that children living together with siblings or other youths have more opportunities for active play [25,26]. Also, single children may have more influence over their parents in choosing their own activities and health-relevant behaviors [62]. Household structure, socioeconomic status, and investments are intertwined attributes of a child's environment. In the U.S. and other Western countries, children from poorer families are often are more likely to develop obesity [93][94][95][96]. In this cohort, at age 5, the prevalence of obesity was highest among children from the poorest 40% of families; across elementary school, it was highest among children in the next-to-poorest quintile, reaching 25.8% by age 14 years [1]. At the same time, having accounted for economic resources and multiple other characteristics, it may be that household structure arrangements that facilitate even more resources do not have healthier child weight in an environment where the most common nutrition-related health problem is not underweight but obesity. Children living with stepparents have been shown in other studies, including from the U.S., to have lower access to resources, including resources pertinent to health [28,42,44,45,47]. In this study, we found that they do not gain more weight during elementary school or have higher risks of incident obesity in childhood. Grandmothers, who often provide either additional economic resources or care and supervision for children, do not improve outcomes in the domain of body weight. Similarly, having more children in the home, which may decrease per capita resources, nonetheless was associated with less weight gain and obesity. A limitation of this study is that we could not take into account the quality of interactions among household members or the duration of parents' relationships, which are likely to be pertinent to child wellbeing. Some children are in dual custody arrangements, spending some of their time in multiple households, and we have only accounted for the structure of the household where they spend the most time. We did not distinguish children living with samesex parents. We also did not identify which household interactions and activities are associated with weight trajectories. A recent study using the same longitudinal cohort showed that, after accounting for weight at younger ages, standard behavioral factors -intake of fruit, vegetables, fast food and soda, television viewing, and physical activity-individually had little or no effect on subsequent weight [97]. This pattern indicates that future studies should take a comprehensive approach to measuring the behavioral links between household structure, home environment and children's weight. The practical implications of these findings raise questions about household investment strategies in a world of caloric abundance. Historically, across cultures, a crux of households investments to promote child wellbeing have been to provide abundant, tasty food and to protect children from caloric depletion and exhaustion by reducing the amount of heavy work or exhausting travel. It may be that these strategies perpetuated in the contemporary world entail the provision of excessive caloric intake through large portions of palatable food and insufficient caloric expenditure through safe, yet sedentary leisure and learning, often in front of a screen. These strategies may continue to signify care but may not be protective against excess weight gain in childhood and obesity. --- This manuscript is a secondary data analysis of publicly available data. The data are available after registration from the National Center for Education Statistics at: https:// nces.ed.gov/ecls/kindergarten.asp. ---

Studies from the social and health sciences have tended to view the household as the locus of access to and distribution of care, resources, monitoring and modeling for children's wellbeing. Obesity may present a special case for the study of investments in children, being a component of health for which more of certain inputs may not lead to better outcomes. We expanded on common measures of household structure in the child health literature by considering co-residence and relatedness of parents, grandparents, other relatives, and other children. Data were from a longitudinal sample of 6,700 children participating in the Early Childhood Longitudinal Study Kindergarten Class of 1998-99 (ECLS-K), the largest U.S. national dataset with measures of child anthropometrics and household structure at seven time-points over nine years. We used lagged survey-adjusted regressions to estimate associations between household structure and subsequent changes in children's weight between ages 5 and 14 years in terms of BMI gain and incident obesity. Adjusting for household structure more thoroughly, children living in households with two parents rather than one parent did not experience advantages in terms of less excess weight gain or lower incidence of obesity during elementary and middle school. Children living with a grandmother gained more weight than children not living with a grandmother. Living with siblings and with non-related adults was associated with less weight gain. These findings corroborate a scenario in which, for health problems associated with caloric surplus, classic household factors have more complex associations with child wellbeing.

is defined by trust in others and/or civic engagement -is a crucial factor of happiness, wellbeing and prosperity. But what does it take for a community to have high levels of social capital and thus become happy or prosperous? According to Layard, the happy community is the stable community. This, for him, comes into conflict with the logic of economic growth, in which mobility is a good thing because it benefits the economy. A high-turnover community is rarely friendly. Yet economists are generally in favour of geographical mobility since it moves people from places where they are less productive to ones where they are more productive. But geographical mobility increases family break-up and criminality… [I]f people are more mobile, they feel less bonded to the people among whom they live, and crime is more common . Layard's conclusion has gloomy implications for high population turnover, but also for immigration and ethnic diversity. In fact Putnam, whose work forms the bedrock of Layard's argument here, has elaborated his theory of social capital to argue that ethnic diversity has a negative impact on community cohesion . Layard himself pays little attention to this issue, but he does mention in the second edition of Happiness that becoming aware of Putnam's research on diversity has made him 'even less enthusiastic about migration ' . Layard's scepticism about immigration is in line with the work of Paul Collier , who offers an elaborate discussion of the negative effect of immigration/diversity. Collier, like Layard, draws on Putnam's work to argue that high levels of immigration are detrimental to community life and happiness. He claims that low levels of immigration may indeed lead to positive economic and social outcomes, but large numbers of immigrants will likely be a disruptive presence for the host society: 'both the economic and the social effects [of rapid immigration] would most probably be adverse for host populations ' . These remarks by Layard and Collier suggest that theorizing community in terms of social capital leads to the conclusion that stability and ethnic homogeneity are good for prosperity, while rapid change and ethnic diversity can in fact be detrimental. In this article we concur with Layard and others that market-centred ideas are insufficient for understanding community prosperity. However, using new data on diversity from a pilot study in the London Borough of Newham, we argue that the theory of community used in their research is too narrowly focused on social relations and undertheorizes the effects of discourse. In our research we examined the locallyspecific cultural constructions of the good life in Newham. We found that 'community' was commonly evoked as an important aspect of what makes Newham a good place to live, but also that the term had two different symbolic meanings, corresponding to different sets of social relations -one which includes everyone in the area, and another which only refers to a small group of diverse but socially engaged residents. Taking this dimension of symbolic/discursive meaning into account has important theoretical and methodological implications. Theoretically, as we show below, discourse and naming have significant consequences for the psychology of identity and the organization of social relations. A theory that addresses the symbolic aspects of community -specifically the ways in which the term is constructed, circulated and used by various social actors -can tell us much more about social life than one that omits this symbolic dimension. Methodologically, the symbolic aspect of community faces the issue of being extremely difficult to measure and aggregate. On the positive side, however, a symbolic approach helps us to be more sensitive to the ambiguity of the concept of community as used by social actors, and to avoid reifying it into a narrow academic category incongruent with people's complex experiences. A symbolic approach, in other words, allows us to operationalize the concept and understand its meanings, uses and effects in a specific political, demographic, and historical context -something which the one-size-fits-all notion of community as defined by trust and/or civic engagement is not nuanced enough to achieve. In light of this, we put forth a multi-dimensional theory of community -one based on social relations and symbolic representations as closely intertwined -in order to better understand the relationship between community and prosperity. We specifically focus on the Stratford area in the London Borough of Newham -an ethnically diverse area with a long history of migration and high population turnover -to find out if ethnic diversity and demographic change do in fact lead to poor quality of community as Layard and others suggest. --- The social and the symbolic: community reconsidered Social relations are core aspects of community but they comprise only one dimension of it. Another dimension is that of symbolic representations which circulate at the national and local levels . The symbolic aspects of community have been famously theorized before. Anthony Cohen , for example, argues that communities are 'symbolically constructed' -they are based on their members' identification with shared symbols. Benedict Anderson's theory of nations as 'imagined communities' is also based on a symbolic approach. For him, the circulation of media representations allows people to identify with others whom they have never met in person, and to imagine a commonality with them that creates a sense of national belonging. Furthermore, as a number of authors show, discourse and naming have the power to transform the way in which objects, actions, individuals and groups are perceived in everyday life . As Ruth Levitas puts it '…the idea of discourse underlines the fact that the matrix of concepts through which we understand the social world and act in it profoundly affects those actions and thus the world itself, without denying the material character of social relations ' . What is more, the act of naming -specifically when it comes to race, gender, class and sexuality -has the potential to inscribe identity onto the subject and to shape its relationships to self and others. Kwame Anthony Appiah summarizes this point concisely: Once labels are applied to people, ideas about people who fit the label come to have social and psychological effect…So the labels operate to mould what we may call identification, the process through which individuals intentionally shape their projects -including the plans for their own lives and their conception of the good life -by reference to available labels, available identities . Appiah's argument refers to labels such as race, gender, and sexuality -what does it mean to be labelled black or white, female or male, straight or gay? These questions are crucial for understanding wellbeing and prosperity and the life trajectories through which people succeed or fail to attain the good life. We would argue, however, that Appiah's theory is also applicable to the concept of community, as well as related concepts such as anti-social behaviour and volunteering. What does it mean to be a member of the community? What does the valorisation of volunteer work do to the act of volunteering? What happens when someone is called a responsible citizen while someone else is labelled 'anti-social'? Consider as an example the notion of volunteering discussed earlier. On one level -that of social relations and their psychological effects -volunteer work, as the data shows, can be potentially beneficial for wellbeing. But on another level, the circulation of political discourses about the benefits of volunteering can also create new regimes of power and exclusion. As Levitas argues, the emphasis that the New Labour government in the UK put on the importance of volunteering in the 1990s created a new conception of what it means to be a good citizen and community member. As a result, those who volunteered fit within this conception while those who didn't were excluded from the label, and were by definition not good citizens. In such a discursive context, 'volunteering begins to appear not all that voluntary' , it becomes obligatory if one is to be recognized as a good citizen in the eyes of the state and of fellow citizens. '[T]hose who do not choose to help are by implication lesser citizens, as well as less "developed" as individuals ' . Volunteering, in this instance, in no longer just a way of making the neighbourhood a better place or improving one's own wellbeing; it is now also a way of judging people's worth as citizens. Similar concerns have been expressed about the concepts of happiness and wellbeing . As Ahmed argues, the idea of happiness can become co-opted by normative regimes of power that regulate social behaviour, often with sexist, homophobic, and racist consequences. Ahmed supports her claim using the tropes of the 'feminist killjoy', the 'unhappy queer', and the 'melancholic migrant', all of whom refuse to comply with hegemonic regimes of identity for one reason or another . These figures, she argues, are often seen as stubbornly senseless because by refusing to comply with the symbolic law they are ruining their happiness, and sometimes also the happiness of others. Similarly, Cederström and Spicer claim that the institutional promotion of wellbeing in many western countries is underpinned by a new image of the good person, namely, 'someone who is autonomous, potent, strong-willed, and relentlessly striving to improve herself ' . But, the downside to this project is that a constant social and institutional pressure to fashion oneself in accordance with this image often causes guilt, anxiety, selfblame, and depression, which are actually detrimental to physical and mental wellbeing. Such critiques, to be sure, do not nullify the analytical and political value of happiness and wellbeing theories; the fact remains that we need to develop and promote alternatives to narrow materialism if we plan to address the crisis of planetary sustainability . Instead, the point we should take from these critiques is that happiness, wellbeing and prosperity have a powerful symbolic side to them, and we should be cautious about their potential use in the service of power and exclusion. --- The concept of community and its political life in the UK, 1997-2015 Since the late 1990s the concept of community in the UK has itself become a central facet of political discourse and policy decisions. This was the case firstly under New Labour , and secondly, under the Conservative-led coalition and its ideology of 'the Big Society' . The New Labour governments of Tony Blair and Gordon Brown used the concept of community in a number of policy areas including, welfare, housing, and urban regeneration . Their community-based politics were grounded in the views that devolution of power leads to more responsive governance, and that people's identities are locally-grounded and must be locally governed . New Labour's ideology of citizenship and community, emphasized that with rights and benefits come obligations. Access to welfare, housing, social inclusion, belonging and respect -in short access to prosperity -was not unconditional, but dependent on people's ability to meet their obligations as law-abiding community members. Community became a short-hand for those who followed the rules, as opposed to those who engaged in 'anti-social behaviour', defined as 'causing trouble, annoyance or suffering to the community at large' . In this discursive opposition between the community and its adversaries, the latter were seen as a problem that had to be addressed through policing, moralization, and social programs . When the Conservative-led coalition succeeded New Labour in 2010, it espoused a similar commitment to tackling anti-social behaviour, albeit with a more victim-focused emphasis . The Coalition also remained committed to devolution of power and community governance. This approach tallied with the more fundamental conservative agenda to minimize the role of government and to make communities and individuals more self-reliant . However, discourses about community cohesion in Britain were not only about the politics of social exclusion and inequality, but also about the politics of multiculturalism. Class identity and cultural/ethnic/racial identity each form the basis of competing models about how British society is divided, who gets left out, and what needs to be done to improve social cohesion. New Labour's emphasis on responsibility, in continuation with earlier Thatcherite trends, undermined the significance of class-based politics and even made the concept of class taboo . As a result, people who previously identified as members of the working class, and who suffered from the economic and social hardships of deindustrialization, were now expected to assume personal responsibility for moving up the social ladder as opposed to relying on organized labour movements. Yet, at the same time, New Labour supported a multiculturalism in which 'community life for black and Asian people living in relatively poor neighbourhoods was configured not through language pertaining to the socio-economic commonalities of a multiracial British working class, but through dominant discourses of racial, ethnic and cultural distinctiveness' . In terms of class, people who fell out economically and socially were stigmatized and excluded. In terms of ethnic/racial identity, minority communities were supported by the government in virtue of their minority status, and offered resources to fulfill their culturally specific needs . From the mid-2000s onwards, however, this multicultural policy created a backlash, especially in the aftermath of the 7/7 London attacks and a series of riots in Bradford, Oldham and Burnley . In the aftermath of these events, public figures were now arguing that because of multiculturalism, Britain's ethnic communities lived 'parallel lives', while Britain itself was 'sleepwalking to segregation' . Political discourse was now increasingly concerned with criticizing multiculturalism and emphasizing the importance of bringing ethnic communities together. As David Cameron put it in a 2011 speech: Under the doctrine of state multiculturalism, we have encouraged different cultures to live separate lives…We've even tolerated these segregated communities behaving in ways that run completely counter to our values…This hands-off tolerance has only served to reinforce the sense that not enough is shared . The quality of community life in Britain since the 1990s has thus been articulated along two defining axes, each unstable and subject to change: one axis based on class and social inequality, which were mostly articulated in terms of personal responsibility; and another based on ethnic division that prevented cultural communities from coming together into a single cohesive community. --- The concept of community in London's East End It is clear that the concept of community has been an important part of British politics over the past two decades. But if these discourses were disseminated at the state level, then what did community mean for people on the ground in Newham? How did local uses of the concept correspond to social capital and social relations? How did the demographic composition of a place like Newham impact the quality of community life, wellbeing and prosperity? London's East End has a reputation for being the historical home of Britain's most robust community spirit. The East End's white working class has long been portrayed in popular culture and academic writing as poor but proud, and always sticking together in the face of adversity . However, East London is also a historical entry point for immigrants, and since the 1960s it has become one of the most ethnically diverse places in Britain . The diversification of East London has transformed the notion of community and set the ground for two discourses on the relationship between community and diversity. The first of these is a narrative of loss in which immigration/diversity has alienated the old community spirit and replaced solidarity with ethnic animosity . In this discourse, 'white East London and a British blend of morality…is contrasted with the immorality of post-colonial non-white immigration' . The second discourse portrays a different scenario; in it, the community spirit of the new, diverse, East End is as strong as ever because people from different ethnic and religious backgrounds respect one another and commit to their shared neighbourhoods . These two discourses are diametrically opposed -one is about interethnic tensions, the other about interethnic solidarity -but they are both grounded in social realities in the East End. In some places such as Tower Hamlets, there is indeed a history of conflict between indigenous white people and newcomers . In Newham too, as James reports, some people express nostalgia for a lost white working class solidarity. Yet, at the same time parts of East London such as Hackney and Newham provide evidence that diversity is in fact compatible with civility, respect for difference and a flourishing community life . Within this context we ask what the concept of community means for people in Newham today, and what it can tell us about prosperity in the area. In the next section we set the background of our findings by presenting some key data about the demographic, economic and social conditions of the borough. Then, in the following section, we present some of our own interview data on residents in Stratford. The data was collected by a team of academics and 'citizen scientists' -local residents whom we recruited, hired and trained to assist us with the research, and who carried out interviews with people in their local neighbourhoods. We specifically focus on residents who were employed, and were therefore more likely to hold a privileged place within the ideological division between law-abiding 'aspirational' citizens and 'anti-social' groups. On the basis of our interviews, we found that many Stratford residents saw their community as ethnically diverse and took pride in being part of a multicultural and vibrant community life. However, we also found that inclusivity of ethnic difference coincided with the exclusion of social groups who were considered detrimental to local community life. --- Newham: a short background The Borough of Newham is one of the most deprived areas in London. According to the most recent data available, its average household income in 2013 was £34, 260, the second lowest in London after Barking and Dagenham , and significantly lower than the London average of £39, 100. As mentioned earlier, Newham is also extremely diverse. It has five ethnic groups that each make up 10% or more of the population, in addition to a number of smaller ethnic groups . Newham, furthermore, has one of the highest population turnovers in all of London . In 2007/2008 19.5% of residents either left or entered the borougha significantly higher number from the London average of 13.6%. Much of this population churn was due to international migration, which in the same period accounted for 4.6% of the Newham population but only 3.5% of London's . Considering these factors, it might be expected that in accordance with the aforementioned theories of Putnam and others, the quality of community life in Newham is quite poor. If diversity, immigration and high population churn all contribute to poor social capital, then surely social capital in Newham would suffer, as would wellbeing and prosperity more generally. The available data on community and social capital in Newham points to contradictory conclusions. While some studies argue that social capital in the area is quite low , according to others this is not the case . The most recent, and perhaps most rigorous, quantitative evidence that we have on the topic is a 2009 Ipsos MORI poll, which asked people in England 'how well they think local residents from different backgrounds get on together'. This survey question does not directly measure levels of trust as Putnam's work does, but we think that 'getting on' resonates with social connectivity closely enough to serve as a homologous indicator of social capital. The poll found that 68.3% of Newham residents agreed with the statement -a figure which, although promising, is much lower than the 76% average of both London and England . What this poll captures well is a general feeling of social fragmentation and disconnection in Newham -one which is much more acute than in other parts of London. This, in turn, is reflected in people's narratives about local life. As Thompson et al. found out, '[n]arratives of social fragmentation were frequently encountered among Newham residents. [This was]…the social reflection…of a borough believed to be disconnected from local services and governance, and home to a transient and often isolated population' . In line with Putnam and Layard's theories, these findings correspond to high crime rates and low levels of life satisfaction. Newham, according to Ipsos MORI, has the lowest lifesatisfaction in London and the highest perceptions of neighbourhood anti-social behaviour . To tackle the borough's apparent community division, Newham council has devised a number of strategies to address both economic/social inequality and ethnic 'segregation' within the borough. In the recently published 'Sustainable Community Strategy' , the mayor of Newham, Robin Wales, outlines a number of 'key principles' for community improvement, including 'building personal and economic capacity'. This entails 'challenging dependency on the state [while considering that] work is the only sustainable way out of poverty', as well as '[p]roviding alternative routes [for success] for young people not attracted or suited to academic learning' . The aim of this strategy is to offer people employment and training opportunities that will help them lift themselves out of poverty and welfare dependence, and become integrated members of the Newham community. At the same time, however, Wales has also made efforts to stimulate ethnic integration in Newham by slashing funding for translation services and removing foreign language newspapers from libraries, while channeling funds into English language classes . These policies, according to critics, do very little for integration because they mainly impact elderly people who are the main users of the services in question . Wales, furthermore, has pledged to refuse council funds for events that only involve a single ethnic or religious community. According to him, '[w]e won't support single ethnic or religious groups to do things themselves within those groups, it's not our job to support that…Our job is to support when people come together' . Given the extreme diversity of Newham and the fact that its minority groups are very small and nonconsolidated, it is questionable whether any ethnic or faith group can remain insular and exclusionary. As Wessendorf shows in her ethnography of Hackney, social contexts where diversity is so prevalent make it practically difficult, if not impossible, for people to not mix and to not be civil towards one another. In our experience, Wales's idea of including everyone resonated with the values of many Newham residents, and as our interview data show below, inclusiveness in cultural events could help people feel as a part of the community. However, we also found that our interviewees were not concerned with the area's ethnic diversity but were rather anxious about the inequality, deprivation, and anti-social behaviour they witnessed on a daily basis. Yet while this situation is captured, at least in part, by the council's 'community strategy' for improving people's economic lives, neither quantitative studies on social capital, nor the theories of prosperity/happiness/wellbeing that make use of them are sensitive to the unstable balance between the axis of class and the axis of ethnic relations. Close ethnographic consideration also shows that there is a more complex and multi-layered dynamic of community than a quantitative study on social capital can capture. In fact, it shows that there are two types of visions of community in Newham and therefore two levels of social capital operating simultaneously and overlapping: one type of community is cohesive and socially engaged, while the other is troubled by anti-social behaviour and tensions between different social groups. Vicky Cattell notes this duality in her study of social networks on a Newham estate, claiming that 'there is a thriving positive community which co-exists with the demoralized community ' . On the one hand, she says, '[f]ear of crime was a constant undercurrent. Residents suggested that coping with a deprived and hostile environment may be acting to damage close relationships ' . Yet, on the other hand, 'there are many very positive aspects of life on the estate [including]…opportunities for involvement in projects, self help groups, tenants' groups as well as courses, toy libraries and so on ' . Our findings lead to a similar conclusion about two communities, but they also point to the importance of diversity in local understandings of community. While Cattell hardly discusses diversity and ethnicity , we emphasize that both versions of community in Newham -the vibrant and the demoralized -were seen as diverse. --- Newham's two conceptions of community The two conceptions of community discussed above were reflected in two different ways of speaking about community and belonging among the Stratford residents we interviewed. On some occasions, our interviewees referred to a multi-cultural network of people getting along, participating in common activities, and trying to create a welcoming environment for all. We call this group 'the community' because it had secured the strongest association with the term, not only among those who saw themselves as a part of it, but also for those who stood outside. This usage resonates with that promoted by New Labour, in which a socially engaged community is opposed to anti-social behaviour. Yet, at other times, people spoke about community and belonging with reference to everyone who lived in Newham, in which case crime, prostitution, and drug abuse contributed to weak community cohesion and a weakened feeling of belonging. This duality was perhaps best illustrated by Halima,1 a middle aged woman who moved to Newham in the early 1990s. When asked if she felt that she belonged, Halima expressed ambivalence: 'That's a tricky one actually, because I think I do in certain circumstances and then sometimes I feel really out of my depth...' She then elaborated what this meant. On the one hand, she had worked as an English teacher, and this made her feel an affinity with different migrant groups. In terms of feeling connected to the area, I have become increasingly connected…I've got lots of friends in the area and I also work in the area…Now I'm an [English] teacher in Newham so I feel very, like a strong connection to the area and I feel like I understand the community and various different community groups quite well…I actually really value it [the community] now. But, on the other hand, Halima also expressed discontent with the pronounced antisocial behaviour in her neighbourhood: We have had anti-social behaviour problems on our street…drugs and prostitution basically so at times I've felt fairly uncomfortable on my own street and that's a horrible feeling actually. But then you shut your door on it…then you forget about it. Mostly, I would say I feel comfortable and I feel belonging and I feel part of things. Here the community is fragmented because of antisocial behaviour, crime, illicit sex work and social inequality. These issues make it difficult for Halima to find a sense of belonging. But at the same time, 'the community' is diverse yet cohesive because of cooperation and mutual respect. It is something that Halima is glad to be part of. As she put it herself, 'there is crime, definitely…but that's sort of made up by some really positive things like the diversity of the place and actually quite a lot of acceptance'. Flora, another Stratford resident who originally came from continental Europe, referred to a similar dual experience of community and belonging. She expressed pride that in Newham people of different ethnicities get along well. Newham, she told us, should serve as an example for the world of how people live together. When we asked Flora what makes someone a member of the community, she explained that one must contribute to neighbourhood activities and actively engage with others. She then offered two examples of her own efforts to be an active member: in the first example, she volunteered at her children's school, while in the second, she took part in a Neighbourhood Watch to help her neighbours stand their ground against local crime Interviewer: Do you feel that you are part of the local community in Stratford? --- Flora: Yes Interviewer: What makes a member? Flora: When you contribute a bit…With the children's activities I used to go and help -if the children were taken to a museum I would be one of the parents along to help. Also, three years ago it got really nasty here with the crime. And as a street of really great neighbours we partnered together to form a Neighbourhood Watch and we started to really angrily stand our ground against the criminals...That makes me feel like a strong member of the community… Here, Flora does not explicitly refer to the wider group of Newham residents as a community, but she does evoke the opposition between the law-abiding community and 'the criminals' who threaten its wellbeing. The community, according to her, is about reaching out, but as her Neighbourhood Watch example shows, it also comes together in opposition to anti-social adversaries who disrupt the peace of the neighbourhood. But while in some cases opposition to anti-social behaviour helped bring neighbours together, in others trouble on the streets prevented people -especially non-established residents -from making friends. Priya, a woman in her twenties who lived in Stratford for five years, told us that she could never establish a connection with the community, despite her efforts to do so. She was fond of public events and gladly participated in them because they were inviting to everyone and brought the community together. However, problems with crime, drugs and prostitution made her feel unsafe and pressured her to stay at home. When asked about her experience of community, Priya responded with enthusiasm: Interviewer: How did you connect with your community…[in Stratford]? Priya: …When it was major events, like when the Olympic torch came, when it was…'Vaisakhi' [a Punjab festival] in Green Street, and when there was that fete going on…just off Woodgrange Road, and there was like clothes and food and cupcakes, and all sorts of things there. And then you just felt like, oh, this is everybody that lives in my community and everybody's come altogether no matter what their religion is, what their thoughts are and what kind of background they come from. Later in the interview Priya emphasized that events like the Vaisakhi contribute to the multicultural spirit of community: they 'bring the whole community together so it wouldn't just be Asian people, it would be everybody…everyone came, and it was great...'. Yet, at the same time, Priya explained that her efforts to be more involved were challenged by crime and illicit sex work: Everyone wants to look after themselves. If you're living in that sort of area, you know it's dangerous…you just don't want to get involved…You're worried that, oh god I live by myself and anyone can walk through my door right now. Because that's happened to us in the past…You know, people could knock on our doors and it was horrible…Once we had our doors getting knocked at, we thought, me and my neighbour thought it was her husband, we open the door and there was a prostitute standing right out there, outside our door, asking us to let her into our houses. Obviously we didn't let her…She started saying give us your phone…I was like, I'll call the police for you if you're having an issue, but yeah, things like that. You don't want to live in an area like that where you don't feel safe in your own home. Priya saw herself as standing outside of 'the community'. She wanted to participate but could not do so because of fear for her safety. The problems in her neighbourhood were so conspicuous, and even intrusive, that she had to barricade herself instead of becoming socially involved. --- Conclusion: community beyond social capital Building a cohesive community by creating strong social bonds is an important aspect of happiness, wellbeing and prosperity. As we show in this article, one indicator for assessing the quality of community life is social capital as measured by trust and civic participation. Consequently, a good way to strengthen communities is to improve their levels of social capital. As the major texts on the topic suggest, this could be achieved by addressing the problems of high population turnover, and high levels of immigration and ethnic diversity. But, theorizing community exclusively in terms of social capital and social relations misses the crucial reality that people can have multiple experiences of community that link to the demographic composition of an area, as well as to its history, politics, and circulation of discourses. In Stratford, and in Newham more generally, there are two sets of community relations -one fragmented and characterized by poor levels of social capital, the other cohesive and engaged. The aforementioned Ipsos-MORI poll on people of different backgrounds 'getting on' captures the first aspect of this duality but not the second. It tells us that in Newham feeling of fragmentation and disconnectedness are far more prevalent then in other parts of London. Yet, what was not registered by the poll was that within the general feeling of fragmentation, many people were committed to, and actively working to create a vibrant community based on diversity and acceptance. This was a second set of social relations that was structured and organized by symbolic representations and ideas about what a community is and who ought to be included/excluded. A comprehensive approach to community -one which addresses people's ideas about community and belonging, in addition to the quality of their social relationships -can lead to significant outcomes for understanding social dynamics and making policy recommendations. The people we interviewed in Stratford emphasized on numerous occasions that ethnic diversity was a positive thing, and that they took pride in being members of a diverse community. Recent ethnographic research confirms that this is also the case in other parts of East London . So in contrast to the findings of Putnam and others that ethnic diversity undermines community cohesion, our data -even if it is representative of only one group of Stratford residents -suggests that diversity can in fact be an integral and highly-valued part of a strong community. But what must be emphasized is that in the context of deprivation, anti-social behaviour, and ideological polarization between 'the community' and its adversaries, it is easy to focus on the social fragmentation that the poll data so clearly reveals, and to lose sight of how valuable diversity is for whatever social cohesion there is in the area. This opens the door for a potentially dangerous misunderstanding of the causes of social fragmentation. At the present moment at least, building a stronger community in Stratford and Newham should have little to do with addressing ethnic diversity and much to do with social inclusion and exclusion. Those people whose wellbeing and prosperity benefit from social cohesion in the area are already a diverse group, and for them ethnic difference is not the main issue. For them, the problems are about poor access to housing and jobs with a living wage, as well as pronounced crime, drug culture, and illicit sex work, all of which keep the wider community divided. What this means for Newham is that any project of prosperity that is premised on building an inclusive community must address the deprivation and inequality at the heart of these issues. What it means for theories and policies of prosperity in general is that they must acknowledge that community life is a context-specific, multi-layered, social and symbolic phenomenon that goes beyond any single notion of social capital and social cohesion.

Researchers and policymakers working on prosperity, happiness and wellbeing in the UK have recently reworked GDP-centred notions of progress and identified community and belonging as major determinants of a good life. The dominant notion of community in most writing on this topic draws on Putnam's work on social capital as measured by trust and/or civic engagement. This approach, however, captures only the social aspect of community, without addressing the symbolic dimension of political discourses and their national and local effects. Using data from Newham, London, this article argues that a narrow focus on social capital obfuscates the complexity of community dynamics, leading to misconceptions about the causes of social fragmentation. In the case of Newham, we show that while survey data on social capital suggests that diversity is detrimental to community life, a more nuanced analysis reveals that it is in fact an important part of community cohesion.

Introduction Behaviour problems are a common reason given by owners for relinquishing their dogs to rehoming centres. A 2010 study found that "problematic behaviours" were the most common reason reported for the relinquishment of dogs to Dogs Trust centres, with 34.2% of all owners giving this reason, and 55.1% of owners who had previously obtained the dog from Dogs Trust [1]. A US-based project found that 40% of owners relinquishing their dog cited at least one behaviour-related reason [2]. There is evidence that both behavioural advice given to puppy owners [3] and owners attending training classes in early years [4] are associated with a reduced risk of undesired behaviours in later life, which may lead to fewer dogs being relinquished. Identifying approaches which encourage owners to access training or appropriate sources of advice is therefore likely to be important in reducing the occurrence of problem behaviours and risk of later relinquishment. Dogs Trust Dog School is a programme that delivers classes for owners and their dogs across the country. The aim of Dog School is to help owners build strong, positive relationships with their dogs, in order to help prevent the development of behaviour problems in the future . During classes, owners are taught how to train their dogs for everyday activities, such as walking on a loose lead, coming back when called and settling down as needed. In addition, a significant part of the classes involves educating owners about their dog's behavioural needs to prevent the later development of problems such as separation anxiety, fear and aggression. For example, classes include information on the importance of consistent interactions, how to introduce new people and dogs, and the gradual introduction to new situations and being left alone. Dog School is affordable to many owners at £55 for an induction session and 5 practical classes. However, it is likely that there are those for whom £55 is a substantial sum for a non-essential service. The current study piloted two free-to-use versions of Dog School, collectively called Introduction to Dog School targeted toward people from low SES communities who may not be able to afford standard Dog School. However, even where a service is free, there may still be barriers which prevent people from low SES communities from attending . As far as the authors are aware, no studies to date have investigated the accessibility of dog training and behaviour classes to people with low SES. The closest analogue for which there is research available is the participation of parents in free behavioural programmes for children. These programmes involve running classes or workshops for parents which teach parenting skills to reduce behavioural issues in children and are often targeted at disadvantaged families. Some preventative programmes for child behaviour problems have observed lower participation rates from families with low SES [5,6]. Families who dropped out of a child behavioural therapy programme have also been reported to be more likely to be experiencing socioeconomic disadvantage than those who completed the programme [7]. Considering the above evidence, it was hypothesised that merely providing free Dog School classes may not make dog training classes completely accessible. The ITDS study gave owners the option to enrol in the course in one of two modalities: face-to-face classes or online modules. It was hypothesised that the online modality could help eliminate barriers such as time schedule conflict and access to transport and childcare, as the training could be completed in people's own time from home. However, there is evidence that online learning courses are prone to experiencing poor engagement and high rates of dropout [8,9]. The current study aimed to investigate differences in attendance and changes in attitude toward training and behaviour between an online and a face-to-face dog training and behaviour course. The study also aimed to compare demographic factors relating to SES between participants who completed the face-to-face course and those who dropped out, in order to determine whether socio-economic factors affected course attendance. Attendance at Dog School classes taking place in the same geographic region was also measured and compared to ITDS. Finally, changes in attitude were compared between owners attending ITDS classes and standard DS classes. --- Materials and Methods The study methodology was approved by the Dogs Trust Ethical Review Board . --- Participant Recruitment Participants were recruited at Dogs Trust community events in selected target areas with a known high population of people with low SES . Both target areas were in the top 20 English local authority districts, with the highest proportion of their neighbourhoods in the most deprived 10% on the Index of Multiple Deprivation [10]. Community events were held in public spaces such as community centres or town halls. Two members of Dog School staff set up a stand at the chosen community events; attendees of the event either approached the stand spontaneously or were directed towards it by those running the event. Participants were given the choice to sign up either for the online or face-to-face course. Participants were also recruited from owners attending paid DS classes running in the same geographic area. Two of the Dog School venues were located in Middleborough, and two were located in the nearby towns of Stockton-on-Tees, and Darlington. Classes in Stockton-on-Tees and Darlington were included to increase sample size, and this was justified by the fact that they are included in the Tees Valley Local Enterprise Partnership . The Tees Valley LEP was ranked as having the second highest proportion of neighbourhoods in the most deprived 10% in the country on the Index of Multiple Deprivation [10]. All owners involved in the study, both DS and ITDS, had DL or TS postcodes which fell within the Tees valley LEP. Owners attending their first DS class were asked if they were willing to complete pre-and post-course surveys as part of a study to help improve DS services. --- Pre-and Post-Course Surveys The pre-and post-course surveys both contained identical questions on owners' attitudes towards training and behaviour. These attitude questions were in the form of a series of 18 statements; for example, 'In order to have a happy dog, you must show them that you are the "Boss" or "Pack Leader"'. Owners indicted the extent to which they agreed or disagreed with these statements using a 5-point Likert scale. The pre-course survey included two additional questions relating to SES: • Does anyone in your household receive/claim means-tested benefits? • Is your household income less than £15,400 per year ? Means-tested benefits refers to payments by the UK government made to individuals who can demonstrate that their income and capital is below a specific level. The specific income figure used in the second of these questions is the threshold used to classify "low income" by the UK government, it is calculated as 60% of the median household income in the UK . Both these questions were Yes/No answers, with the option to select "don't know" or "prefer not to say". Earlier versions of the survey included a question on educational attainment, but during ethical review the decision was made to remove this question as it was deemed too sensitive. The questionnaires were completed online by owners taking the online course . The questionnaires were printed and given in paper form to the participants of the face-to-face classes. Responses to the paper questionnaires were then inputted into SmartSurvey by the instructor after the class so that all the responses were stored together. Paper surveys were destroyed after the data were transferred to the online survey tool. Both questionnaires had a cover page with a statement which explained the purpose of the study and informed the owner that participation was completely optional. The statement also detailed how the owner's data would be stored. Owners could only proceed to the questionnaire once they confirmed that they had read and understood the statement and were happy to continue. The survey can be obtained by contacting the corresponding author . --- Face-to-Face Classes Face-to-face ITDS classes started the week after the sign-up event, in the same venue. Participants attended a series of three classes . The first class was a presentation on the basics of canine behaviour that underpin training; owners did not bring their dogs to this initial class. The following two classes were practical sessions, where owners brought their dogs and practised positive training techniques as demonstrated by an instructor. Participants were given the pre-course survey to complete at the start of the first class, and the post-course survey at the end of the final class. The course content was based on the 6 class paid DS programme but condensed to 3 classes. For a full list of topics covered in the ITDS course, please see "Supplementary Materials-Course Content". The DS participants started the course with the same introductory presentation given to ITDS participants, followed by 5 practical sessions. Course content for DS can be found on the Dog School website . The same topics were covered in DS and ITDS. However, because the DS course was longer, the participants had more opportunity to practice what they had learnt with the guidance of the trainer. Due to the nature of the classes, the course instructor could adapt the content of the course based on the needs of the owner present. So, classes were not necessarily conducted in an identical manner to the course content plan. Both DS and ITDS classes were group sessions with a maximum of 6 dogs per class. --- Online Course Participants were emailed after the sign-up event with a link to the pre-course survey. On completion of the survey, they were sent a link to the online learning platform and login details so that they could sign in to their personal profile on the platform. The online platform contained three training modules which covered the same topics and structure as the ITDS face-to-face classes . Modules were delivered using a mixture of text, interactive quizzes and videos of canine behaviour professionals demonstrating training methods. Online learners had immediate access to all modules and could complete them in any order they chose. Once online learners completed the course, they were sent the post-course survey . --- Data Analysis Dropout rates were determined by calculating the percentage of participants who did not reach the end of the course. Chi-square tests were used to investigate differences in household income and benefits status between those who completed the course and those who dropped out. The SES of participants enrolled in ITDS and those enrolled in DS in the same geographic area was also compared in order to determine whether ITDS was reaching its target audience. Attitudes towards training and behaviour were measured using the scores from the attitude questions on the pre-and-post course surveys. Reponses were scored on a scale of 0-4: For positive statements , participants scored 4 if they answered "strongly agree" and 0 if they answered "strongly disagree". For negative statements , the scoring system was reversed. Scores for each of the 18 statements were summed to calculate a total score for each participant . Wilcoxon rank sum tests were used to determine whether there were significant differences in total scores between ITDS and DS. Wilcoxon signed rank tests were used to determine whether there was significant improvement on total attitude scores in the post-course survey compared to the pre-course survey. A Kruskal-Wallis test was used to compare median ages of dogs enrolled in ITDS , ITDS and DS. Statistical analyses were performed using R version 3.6.0 , Vienna, Austria). --- Results --- Dropout Rates Dropout rates were high for both the online and face-to-face ITDS classes: 51 participants started the face-to-face classes, but only 29 completed the course . None of the 32 participants who started the online course completed it . The dropout rates observed in the DS classes running concurrently in the same area were lower; of the 58 DS participants who started classes, 44 completed the course . The online course had 19 sections, and there was a function which allowed researchers to see how many of these sections each participant had completed. Only 12 owners completed 1 or more of these sections . The fact that none of the participants completed the online course meant that there were no post-course surveys for these participants. Therefore, it was not possible to compare changes in attitude between the two different modalities of ITDS. The trainer attempted to contact participants who dropped out of face-to-face ITDS in order to ascertain the reason they could not come to class. Unfortunately, the majority of those contacted did not respond. Of the 13 individuals who did provide a reason for non-attendance, five cited owner illness, four cited work commitments, two stated that the dog was not suitable for classes due to their behaviour , one said that the dog had come into season, and one reported that the dog had been rehomed. --- Differences in Measures of Socioeconomic Status Participants who enrolled in ITDS were significantly more likely to have lower household incomes, and to receive means-tested benefits than participants who enrolled in DS in the same geographic area . Of participants enrolled in ITDS, 40% reported annual household incomes of less than £15,400, and 36% said that someone in their household was in receipt of means-tested benefits. Conversely, in DS only 9% of participants reported household incomes lower than £15,400, and 12% said someone in their household was in receipt of means-tested benefits. This suggests that the ITDS programme was reaching the target audience; people with lower SES who may be less able to afford dog training classes. Participants who completed ITDS had significantly higher household incomes, and were less likely to receive means-tested benefits than participants who did not complete ITDS . Of participants who completed the course, 21% had household incomes lower than £15,400, and 17% said that someone in their household was in receipt of means-tested benefits. Conversely, of those who did not complete the course, 50% of participants reported household incomes lower than £15,400, and 46% said someone in their household was in receipt of means-tested benefits. There was no significant difference in SES between ITDS participants who enrolled on the online course and ITDS participants who enrolled in the face-to-face classes . --- Attitude Scores Participants who completed the ITDS course, and participants who completed DS, scored significantly higher on the attitudes section in the post-course compared to the pre-course surveys, indicating an improvement in attitude scores as a result of the course . See Table 1 for median scores in the pre-and post-course surveys. Participants enrolled in DS scored significantly higher in both the pre-and post-course survey than participants enrolled in ITDS . The median change in pre-and post-course attitude scores was four for both ITDS and DS. So, unsurprisingly, there was no significant difference in improvement in attitude score between ITDS and DS . --- Attitude Scores Participants who completed the ITDS course, and participants who completed DS, scored significantly higher on the attitudes section in the post-course compared to the pre-course surveys, indicating an improvement in attitude scores as a result of the course . See Table 1 for median scores in the pre-and post-course surveys. Participants enrolled in DS scored significantly higher in both the pre-and post-course survey than participants enrolled in ITDS . The median change in pre-and post-course attitude scores was four for both ITDS and DS. So, unsurprisingly, there was no significant difference in improvement in attitude score between ITDS and DS . --- Dog Age The average age of dogs participating in ITDS , ITDS and DS was 5 years, 2 years, and 5 months . A Kruskal-Wallis test indicated that the difference in age between these three groups was statistically significant . --- Discussion The primary aim of this study was to investigate the accessibility of dog training classes for owners with low SES, by comparing dropout rates between an online and face-to-face format. Dropout rates were high for both the online and the face-to-face modalities of ITDS; engagement with the online course was particularly poor, with none of the participants reaching the end of the course. This meant that there were insufficient data to achieve the second aim to compare attitude change between the online and face-to-face modalities. However, there were sufficient data to compare attitude change between DS and ITDS. Dog School classes running in the same geographic area had significantly lower dropout rates than ITDS. Participants of DS were also significantly more likely to have higher household incomes, and less likely to receive means-tested benefits compared to ITDS participants. This suggests that there may be socioeconomic barriers to attending dog training classes which cannot be fully ameliorated by removing course fees. Comparisons between DS and ITDS should be treated with a degree of caution due to the differences in class structure. However, the existence of socioeconomic barriers other than course fees is further supported by the finding that owners who completed the ITDS course had higher incomes and were less likely to be in receipt of benefits compared to those who were unable to complete the course. Similar associations between low SES and low attendance have been reported in studies relating to accessibility of free behavioural programmes for children [5][6][7]. Mendez and colleagues [11] found high dropout rates among parents attending a programme of free workshops demonstrating early learning activities aimed at low income families ): Only 40% of families attended two or more meetings out of a possible nine meetings, and only 1.13% of families attended all nine meetings. It could be argued that poor engagement with ITDS reflects a lack of need for dog training in the target community. However, the authors believe this is highly unlikely: Dogs Trust campaign staff, who run multiple responsible dog ownership events in our target communities every week, anecdotally report a persistent high demand for training and behaviour advice. However, because campaign staff are not canine behaviour professionals, they are not fully equipped to deliver this advice themselves. Previous studies have demonstrated that low SES of owners is a risk factor for several canine behavioural problems [12], and increases the likelihood of being hospitalized with a dog bite injury [13]. A report of UK hospital data for animal bites found that "hospital admissions for bites and strikes by dogs are three times as high in the most deprived areas of England as in the least deprived areas" [14]. Furthermore, the UK hospital data report found that the Durham, Darlington and Tees area had the second highest rate of hospital admissions for dog bites and strikes in the country. A study conducted in Liverpool, UK, found that the more economically deprived an area, the more dogs were owned [15]. Finally, the current study found that participants enrolling in ITDS scored lower than DS participants on the attitudes section of the pre-course survey. This suggests that there may be a lower awareness of up-to-date canine behaviour knowledge and the importance of positive training methods in the demographic that ITDS is targeting. Therefore, this demographic is likely to benefit from classes which encourage positive training techniques. Together, this evidence suggests that there is likely to be a need for dog training and behavioural support in our target areas, but dog owners with low SES are less likely to access these services due to various barriers. It is important to understand what barriers may be preventing people from attending dog training classes, other than course fees. Unfortunately, when ITDS staff attempted to follow-up with participants who dropped out, there was a low response rate. Of those who did respond, the most commonly reported reasons were owner sickness and work commitments. A study on barriers experienced by low income parents to accessing The Companion Curriculum also found that work schedule conflict was a prominent reason for parents being unable to attend workshops ; other barriers reported were transport , tiredness and child care needs [16]. It is likely that many people with low incomes have unpredictable working hours; a recent report by the Living Wage Foundation found that over 1 million people in low paid jobs in the UK have "volatile pay and hours", and an additional 1.3 million people have regular pay but unpredictable hours [17]. Further research into the identification of barriers is planned for the next phase of ITDS. A potential factor which could have increased engagement with DS compared to ITDS is the fact that DS classes were paid for in advance. An economic theory, known as the "Sunk Cost Fallacy", suggests that people are more likely to continue a course of action if they have already invested time or money into it [18]. This effect could be investigated in future research by comparing participation in a partially funded or subsidised dog training course to participation in a completely free training course. Another difference between DS and ITDS which may have affected engagement is the methods of recruitment. For ITDS, participants were actively recruited at campaigns events, they were not necessarily seeking to enrol in canine behaviour classes before they came to the event. For DS, on the other hand, participants were not actively recruited, many participants find out about Dog School by searching for training classes or puppy classes online. Therefore, participants in DS were more likely to be people who had actively sought out training classes, which may account for the increased engagement of these individuals. The decision to utilise different methods of recruitment was made because the researchers believed that people with low SES would be less likely to contact DS spontaneously; this belief was confirmed by the finding that people who enrolled in DS were of higher SES than those who enrolled in ITDS. Differences in recruitment may also have accounted for the significant differences in age between dogs attending DS and ITDS. Dogs attending DS were on average far younger than those attending ITDS-it is likely that owners of young dogs seeking puppy classes online came across DS in their search. Conversely, people at community events with an interest in training were directed towards the ITDS recruitment stand, regardless of the dogs age. Differences in age may have impacted on motivation to complete the course; older dogs may have been less trainable than younger dogs [19], which may have discouraged people from continuing the course if they could not see immediate results. The online course was particularly poorly attended, none of the participants reached the end of the course, and the majority did not complete a single module. While the face to face course allowed participants to ask the trainer questions, and receive feedback on their practical skills, the online course did not have these benefits: It is possible that this difference made the online course harder to engage with. Although there has been no prior research specifically relating to online dog training courses, other types of online courses have been shown to be prone to high dropout rates [8,9]. Some people may prefer face-to-face to online learning; one study reported that 62% of students would not be willing to enrol on an online degree programme [20]. Studies have found greater reported course satisfaction and feeling of engagement in face-to-face courses compared to online courses [21,22]. In one study a greater proportion of virtual classroom students reported that they were likely to stop attending class in favour of other activities than traditional classroom students [23]. An improvement to the methodology of the current study would be to include user testing of the online platform with members of the target audience; this could help identify areas where participants were likely to disengage with the course. Particular attention should be paid to the user experience when first starting the course, as many participants did not complete a single module, suggesting that the course could do more to engage participants initially. There is increasing evidence that gamification of online courses can increase user engagement [24,25]. There is also evidence that giving learners social networking opportunities can increase engagement with online courses [26,27]. Future development of online dog training courses should, therefore, consider the use of gamification and social networking as possible methods of increasing user engagement. The next phase of ITDS will take into account the findings of the current study in a number of ways. It is recognized that understanding the barriers faced by people with low SES is a complex issue; due to the nature of our data it was only possible to run relatively simple statistical tests, which may not have taken into account all factors involved. In the next phase of ITDS, participants will be interviewed in order to collect in-depth qualitative data on barriers to training. The intention is to interview both participants who are unable to attend and those who are able to attend, in order to gain insights from different perspectives. The next phase will also involve user testing and focus groups on the online course within our target communities, the aim of which will be to identify factors which discourage people from continuing with the course. A future aim is to include a limited number of partially funded places on existing DS courses. This may utilise the effects of the "sunk cost fallacy" but will also be a more cost-effective way of delivering training compared to running completely separate classes. --- Conclusions There are many examples of animal charities offering subsidised veterinary care, for example, subsidised neutering or free microchipping services and People's Dispensary for Sick Animals ). However, as far as the authors are aware, there are no widespread programmes which offer help with the costs of obtaining dog training and behaviour support. The collective findings from this research will help increase understanding of the barriers to attending dog training classes and support the development of training and behaviour advice delivery that is accessible to people with varied socio-economic backgrounds. --- Supplementary Materials: The following is available online at http://www.mdpi.com/2076-2615/9/10/849/s1, Supplementary Materials-Course content. ---

Behaviour problems are among the most common reasons owners give for relinquishing their dog to a rehoming centre. Dog training and owner education classes can help prevent behaviour problems, but some people may not attend these due to cost and other barriers, particularly people on low incomes. This study compared the engagement of dog owners recruited in areas with high levels of socio-economic deprivation who were offered free face-to-face dog training classes or an online dog training course. The study aimed to find out whether the online or the face-to-face formats were better at reducing barriers to learning about dog behaviour. There were high dropout rates from both types of courses; none of the participants finished the online course, and 43% of people did not reach the end of the face-to-face classes. A course of paid dog training classes with similar content, running in the same geographic area, had a comparatively low dropout rate (24%). Participants who completed the free face-to-face classes had significantly higher household incomes and were less likely to receive means-tested benefits than participants who dropped out. This evidence suggests that low income dog owners may face other barriers to attending dog training classes, aside from, or in addition to, cost. Future research should investigate people's reasons for not continuing with dog training courses in order to support the development of training and behaviour advice delivery that is accessible to everyone.

Introduction To achieve a world with more opportunities and a better quality of life people must want to be part of social solutions. To this end, the POZE 1 paradigm addresses social change from different angles that together form a circular embrace of the four dimensions that determine human experience and expression. While the underpinning logic for all of them is the same, Purpose for Power concentrates on the empowerment of the individual, independent of an institution. Compassion for Change focuses on individual reconnection as a means towards institutional cultural change. Influence for Impact is geared towards the systematic use of individual and collective decision-making processes to shape behavior. Common to all is the Honesty for Humility approach, which is about personal authenticity, also called 'leadership'. The worldview that underpins the POZE paradigm, has arisen organically as a result of my becoming. It offers a perspective to understand and optimize human behavior. We are part of a context and whatever we are, do, and become is not only influenced by our surroundings but we also influence our surroundings. A central result of POZE is that this influence can be understood and optimized. Once we acknowledge the multiple undercurrents that determine our existence, we can use this awareness for our own good . When we know what affects our thinking and feeling, our desires and dislikes, and ultimately our behavior, we are no longer the victim of inbred instincts. Usually, we know inside what is good for us, and for others; and this intuitive knowledge is present even while we are doing exactly the opposite. The aim of POZE is to bring the interplay between the visible and the invisible, the interaction between what we want and what we do, to the surface; to make it approachable. Once we have seen how the model operates and why it works across cultures and countries, we conclude with a brief overview of the consequence that a POZE perspective has on the society that emerges from COVID-19. A society that caters to the needs of everyone is beneficial for each of us. In order to make it happen, people in society must grasp this possibility and the duties that derive --but not just intellectually. They must genuinely want to make it happen. Change happens from the inside out, starting with the aspiration of individuals to do something that matters not just for them and their closest kin. This aspiration opens a doubled window, because it entails on the one hand the desire to do something, and furthermore to do it for/with someone else. Once an internal change of attitude and appreciation has begun, it is nurtured from the outside in. Every small concrete action that manifests the new understanding contributes to the gradual emergence of new beliefs and behavior patterns. Personal transformation occurs as organically as everything else. As I am writing this article I am in New York, the national epicenter of the international epicenter, of COVID-19. It is a surrealistic scenario where horror and apparent normality reside side-by-side. The Pandemic that engulfs the world since the onset of 2020 has lain bare a class conundrum that has simmered under the surface for 1 POZE has four meanings: it i) translates as 'inner peace' from Haitian Creole, country where the dynamic began in 2017; ii) is an acronym that encompasses the four core concepts of the paradigm ; iii) is a representation of the four outcomes of the logic ; finally it iv) is stands for an exercise to nurture inner peace daily decades. Growing quietly in our midst we knew it was there but for many of us it was easy to overlook it. No longer. COVID-19 pulled the veil of chosen blindness that had lulled many of us in a lukewarm want-belief that the system that we evolve in works well. If the expected sum is 100 but the actual outcome is 30, something is uneven. Why do we accept it simply because we are part of the 30? Once we are not just looking but actually see, we realize that every day illustrates the different faces of inequity. Every one of us is a potential perpetrator; because if we are not doing something to solve a problem, we are part of it. COVID-19 represents a precious opportunity to change who we are, individually and as a society. We can seize this momentum of a collective wake-up call to make a difference. POZE is about individual and collective change to expand the collective sum to 100. --- The Journey to POZE The POZE paradigm has evolved organically as a result of the author's experience, education, and research. A short overview of her journey is provided to illustrate how POZE works. Born and raised in Germany, in a middle-class family, I won the lottery ticket at birth. It set me on the right track from the start. Growing up it seemed obvious from the start that I had to give back what I had been given. The need to justify why I deserved the privileges that had been placed in my lap from the onset was always there. This led to a range of seemingly incongruent career choices which were all motivated by the same desire, making a difference by making the world happier. Only recently, now in my forties, I came to see that life is not about doing but being. It is not about giving our best but becoming our own best self. We will look at that in section two. To begin with I chose to be an actor. Not with the aim of fame and fortune but driven by the belief that if we can show people how the world could be, they would want to make it happen. I pursued this line of life for a while until 1 day I realized that I had hit a wall. I could not spend the rest of my existence saying what others had written, doing what I was told to do; all the while operating in a vacuum of make-believe that never left the stage. I quit. After a short stint as an au-pair in Brussels where I learned French, I started to study law in Germany while taking care of my ailing grandmother. I believed that I could develop laws to protect those that cannot protect themselves. After 3 years I went to France to graduate in international law. As it turned out, the university where I graduated had a European Master of Arts program on humanitarian assistance . Seizing this first of a series of coincidences , I stayed in France pursuing in parallel another master's degree in international crisis law to maximize the opportunity to learn. However, I realized that the law is only as valid as the willingness of those who implement it to apply it faithfully. Without such willingness a large gap between theory and reality materializes. Thus, I started to think of shifting my focus from humanitarian law to humanitarian work on the ground. Consequently, 2 years later and with my two brand new degrees I went to Mali with the United Nations World Food Program . I ended up staying not 6 months but 3 years. It was dire and delightful. Once again, I was fortunate in so many ways. Having overcome a disease that brought me to the hospital barely a month after I had arrived in the country, I found friends and insights. My boss was the type of supervisor that every young humanitarian worker should have at least once. Committed to work and life simultaneously, he showed humanity in every fiber of his body. It was a time of learning that helped me groom the stamina that I needed as I moved on. Mali was the beginning of nearly two decades on the ground, in some of those countries that appear as the top of the worst from an outsider perspective. Working with the United Nations Children Emergency Fund I went to Chad, working in the border area to Darfur, and Afghanistan, the Democratic Republic of Congo, and Haiti. This range of countries was a question of choice and luck. Being in these places, which are not only afflicted by humanitarian disaster and chronic poverty, but also by a gloomy image in the public eye, allowed me to get a new perspective. It offered me a glimpse of the beauty and the resilience of individuals of all ages; not as words and concepts but as an everyday experience. The people I met had been placed in a life where survival is not a given, and where every day may be the last. And yet they not only just got by, they found the strength to smile and share. From stories to tea, from bread to coffee, so many moments in places that are decried as places of terror and despair have a cherished niche in my heart; because of the individuals who shared their time with me. While stationed in DRC, I did my doctorate by distance with a Law University in France while doing teaching stints in their humanitarian master's program. Seeing, every day, the gap between theory and practice, my dissertation looked at the responsibility to make children's rights come true. About 700 pages later I had answered the question I had been determined to answer . However, I was left with an even bigger question. But if individuals and governments are conscious of their responsibilities, and do not act accordingly. What must change? If despite the multitude of legal conventions that enshrine equal entitlements for all, and thus a fair chance in life, billions are deprived while millions are surfing on a surplus, then something is missing. That set me up for the quest that eventually led to POZE. How can we make people want to be part of social change, and find happiness along the way? As time went by the questions that I had set out with as a young humanitarian grew and got company. While working on the ground, I witnessed too often the gap between rights and reality, between mission and manifestation, between possibility and practice. Humanitarian and development programs are precious and necessary, but increasingly I felt that those who were mandated to implement them remained underneath their potential. It is easy to criticize and hard to improve. Thus, I am far from joining the camp of those who claim that aid agencies should stop operating. Rather my question is what must change inside to make these organizations whose work is direly needed more impactful outside. In 2017 while I was working in Haiti I began to develop and test the prototype of a methodology that eventually became POZE. Translated from Haitian Creole the word stands for 'inner peace'. It was coined by colleagues who experienced the approach first-hand. As it turned out, yet another coincidence, the four letters of the acronym also encompass the four core concepts that underpin it. Purpose, the quest for meaning that drives human existence, "Om", the widely recognized word for emotional unity, Zoom, a mental focus on the essential, and Expression, the manifestation of our beliefs in the world. In 2018 I went to New York to help design UNICEF's global communication and advocacy strategy. Around the same time, I was offered a position as a researcher and lecturer at Deakin University's Center for humanitarian leadership. I decided to take it after completing my task in New York. For my friends and colleagues, the move from a well-paid stable UN career to an academic job with half the salary at the other side of the globe appeared drastic. Since the alternative that I had been playing with in my head for a while was to quit my job without another one to replace it, the move to academia felt like a soft transition. It offered me a transition from the work that I loved but increasingly doubted, to a position prone to improve that field of work. But it was not meant to be. Due to visa issues the move to Australia did not happen But it was too late to continue as before. Once I had popped the bubble of my comfort-zone, it was impossible to reconstitute it. In 2019 I took a sabbatical and began to put POZE to paper. Once again, an apparent coincidence turned out to be a blessing in disguise. The books that brought this article about would not have been written by now if everything would have worked according to plan. --- What is POZE This section explains the twice four-dimensional logic that underpins the POZE paradigm at the individual and collective level. How we live as individuals in this World is influenced by the four dimensions that shape our being: soul, heart, mind, and body. Their expressions are aspirations, emotions, thoughts, and sensations. This intrinsic dynamic renders individuals a symmetrical representation of the society they evolve in. Society is composed of 7.8 billion individuals, each of them a complex microdimension. The next higher level is the meso-dimension, covering families, communities, and sub-national institutions from small to large, that individuals voluntarily and knowingly belong to. The macro-dimension encompasses micro and meso in the form of countries, economies, and cultures. Altogether micro, meso, and macro form the meta-sphere which furthermore includes supranational organizations such as the United Nations, and non-anthropocentric features such as Nature. Engaged in an ongoing spiral dynamic, from the center to the periphery and from the periphery inwards these multiple dimensions continuously interact and influence each other. At the individual level there is a constant set of connections along the continuum of the layers; a spiral dynamic unfolds, connecting the physical and the inner realm in a constant flow, which operates in both directions. Aspirations influence emotions and thoughts , and thereby decision-making processes. These decisions manifest in the form of expressions , words, actions, or gestures that culminate in experiences through physical and sensorial impressions. These experiences generate memories and emotions that will be drawn upon in the future when a similar situation requires an action or decision. Action for others leads to a harmonization of behavior, emotions, thoughts, and the aspiration of living in line with one's values. The resulting experiences confirm a positive self-image, which come with positive emotions and peace of mind. COVID-19 has revealed that everything can change, always and unexpectedly. Amid this omnipresent uncertainty we can however identify and influence the factors of certitude that exist unfailingly. Four principles apply to individuals and society alike: 1) Connection: Everything is linked to everything else. Nothing happens in a vacuum. 2) Change: Everything always evolves. Nothing stays the same forever. 3) Continuum: Everything is part of a scale on which it eventually transforms into something else. Nothing occurs secluded from the rest. 4) Complementarity: Everything stands in complementarity to something else. No phenomenon occurs without a counterpart that completes it. Internally the interaction between our aspirations, emotions, thoughts and sensations influences who and how we are, what we do, and how we interact with our environment. Externally, the mutual interplay between individuals and institutions shapes the society that we evolve in, and the individuals in it. A word on each of these dimensions follows as the basic structure to organize subsequent reflections. --- Individual Dimensions Since Plato, philosophers have described the decision-making process as either rational or emotional . However, neuroscientific findings increasingly prove that that our best decisions are a blend of both feeling and reason, depending on the situation. As Antonio Damasio states, "We are not thinking machines that feel; rather, we are feeling machines that think" . To influence decision making processes, it is crucial to not only think about what we feed the brain, but to also carefully reflect on how the different parts of the brain respond. Within this perspective, it is important to consider an additional angle: error. Research shows the existence of 'systematic' errors within the machinery of cognition, which cause irrational choices independent of 'corruption' by emotions . What we think and do leaves physical traces in our mental hardware. . Emotions are fundamental in determining our opinions, decisions and deriving from them our behavior. Thoughts and emotions influence each other mutually. The soul represents the essence of who we are.2 It is the core of our being and embodies our aspirations. The desire to find meaning in everyday existence influences what we feel, think, and do. . The quest of WHY, the need of purpose is anchored here. It naturally relates to the connection with other beings, and the inherent desire of a shared existence, which involves the sharing of resources . The second dimension is our emotions. Metaphorically speaking they are in the heart. They influence how we feel about ourselves, others, and life overall. WHO we are and what we do, is only partially the result of rational choices; our decisions are significantly influenced by our feelings. . Emotions are commonly defined as "any conscious or unconscious experience characterized by intense mental activity". 3 Physiologically speaking, these mental activities are mostly processed in the Amygdala part of the brain . They can be understood, influenced, and used systematically in the process of personal and collective change dynamics. In basic terms, emotions can be considered and studied as "simple patterned behavioral and physiological responses to specific stimuli" . Neural and psychological research, however, increasingly suggests that there is a tight integration of emotional and cognitive processes, with emotions playing a central role in cognition and decision-making . The third dimension of our being is the mind. Thoughts influence our emotions and aspirations, our physical experiences and expressions; and are influenced by them . Thoughts, ideas and opinions result from an intricate mix of genetic disposition, education, beliefs, memories, upbringing, and environment. Anchored mostly in the mind, they are influenced by hardware aspects such as neurological pathways, hormones, blood-supply, nutrition etc.; and by software elements such as our past and present expressions and experiences. Thus, they stand in constant connection with the rest of our being. HOW we think in the present is not only influenced by WHO we currently are as a person; it is influenced by our past being, and it influences who we evolve into in the future. The fourth dimension is the body, which is one the one hand the outer casing that connects and separates our internal and external realm; and on the other hand, a channel through which we relate to the world. What happens in the physical space has direct impact on our mental and emotional evolution. As an interface between the inside and the outside, the body allows us to experience the World and express ourselves in it; including in the relationship with other human beings. Physiological aspects experienced via our senses impact the way in which we think and feel. The signals taken in by our senses are direct, such as heat or colors, and indirect such as words and interactions with others; they are external, looking at everything outside, and internal, like hunger or pain. Invisible factors such as the state of our microbiome, blood-sugar level, hormone balance, immune system etc. affect our ability to reason, our mood and our attitude towards the world. . Our present mind-set and personality influences how we experience the world. And how we experience our environment influences how we express ourselves in it . It is a two-way road, whereby our physical action is influenced by our mental set-up and it influences it in turn . Nothing happens in a vacuum. The body reflects our internal circumstances. Conversely, our experience of the environment impacts our internal circumstances, shaping our perspective of the World and hereby our reaction to it. Whatever happens at the center radiates out, like a stone cast into the water. Whichever state our internal realm is in -our emotions and thoughts, which are influenced by our aspirations, impacts our perception of and interaction with the outside . Life is like a mirror. Whatever happens around us has a counterpart inside of us; and inversely, what happens inside has a matching part outside. The four dimensions that influence our personal experiences and expressions reflect the four-dimensional dynamic that shape society to which we turn in the next sub-section. --- Collective Dimensions The micro level refers on the one hand to the four-dimensional internal composition of every individual's being; on the other hand, it is a fundamental piece of society. Every person is at the same time part of various meso-entities, different types of institutions and communities . These meso-entities organize and unite individuals within entities that have a group identity, distinguishing them from others; they also function as an intermediary between the individual person and the subsequent macro level; the latter encompasses the economic, political and, cultural spheres that we, and our lives, evolve in. Respectively and combined these three dimensions form part of the meta-dimension which also covers Nature. It should be noted here that the meta level includes also to supra-national organizations and entities such as the United Nations, which have a global mandate and impact. Micro, meso, macro, and meta dimensions mutually influence and shape each other. Whatever happens in one dimension has repercussions within and upon the other ones. Immediately or eventually, directly or indirectly. From here on we will look at the use and application of the POZE model and the implications that derive from it. How we deal with this set-up is a matter of choice. We can focus on one dimension while leaving aside the others. Alternatively, we have the possibility to put the panoply of pieces into a holistic vision, which capitalizes on synergy, and systematically influences their causal interplay. We can leave the outcome of the constellations that influence our existence to pure chance. Then again, we can choose to consciously influence them in view of results that lead us closer to our medium-term and final goals. Acknowledging, analyzing, appreciating, and methodically addressing the twice four-dimensional (i.e. the four internal dimensions at Fig. 1 Everything is connected, from the inside out and from the outside in. Our soul finds its expression in our aspirations. These influence the heart, which is the source of our emotions. How we feel impacts our mind. How and what we think impacts our overall wellbeing, and our behavior. From the inside out and from the outside in. The body is the interface between our inner and outer realities. Experiences influence our mind and heart, our thoughts and feelings. Physical experiences influence our inner realm, while the latter shapes what our expressions, our attitudes, and our behavior in the outside world is and will be the individual level and the four collective dimensions) dynamic that shapes our reality is challenging, but possible. It may appear like an overwhelming endeavor to look beyond personal interests, and in the case of governments of national interests. What we know and have today grants us a power that is far beyond anything previously imaginable. The question is to translate this potential into practice. --- Understanding and Influencing Behaviour Our perception of reality is the result of two complementary forms of experience: direct experience, via our five senses ; and indirect experience, with the intake of information . This information is filtered through our intellectual processes and existing belief systems. Emotions drive us on a subconscious level. Rooted in our past, these emotions influence what we desire for the future. Individuals' past experiences influence their present mood and mindset, as well as the values that dominate their belief system. Beliefs about a certain issue determine our emotions and therefore shape our attitude towards the situation we are currently in. This influences our behavior, which results in an experience that either reinforces or changes our beliefs and impacts our subsequent emotions. Awareness of this connection, combined with attention to emotions, bodily sensations, and thoughts, offers individuals a tool to consciously work on their beliefs and thereby change their experiences. This cycle of mutual influence is ongoing and constant. Aspirations influence Emotions. Emotions influence Thoughts, and therefore Decisions. Decisions result in Expressions that involve Sensations, forming Experiences. Together, these elements create memories. If repeated many times, recreated patterns become habits that gradually result in certain character-traits, which in turn trigger certain emotions during certain situations. It is a spiral that operates in both directions, from the inside out and from the outside in. Once we understand the dynamics that underpin our own behavior, we start to understand the behavior of others. This two-folded understanding enables us to influence both, our own behavior, and theirs. In terms of intensity and impact the various stages of influencing others can be placed on a 'Scale of influence'. The first and lowest stage is Informing. It provides the mind with facts and figures. Yet, no matter how much information we have about a certain issue, emotional impulses influence whether our attitude shifts from knowing about it, to caring about its implications and about those who are affected by it, to genuinely wanting a change of this situation, to actually getting proactively engaged to do something about it. Thus, the second stage involves inducing emotions. The heart is pulled in through stories, images etc. Still, the resulting attitude towards the issue is passive. The third stage is to intrigue the person to rethink their current belief system by providing them a perspective that pushes them out of their acquired mental space. The fourth stage is about igniting. It is anchored in offering the spectator the opportunity to experience what change feels and looks like if someone else does. Thus, change becomes tangible and relatable. Once action is taken, a fifth stage is activated which lies beyond the scale. It is outside the scale because as observers turn into players their action has the potential to inspire other observers to get involved. A new scale begins with the potential to reach further people. An all-encompassing understanding of the human behavior is a major asset to optimize our behavior in view of our own happiness, the happiness of others and the overall functioning of the communities that we are part of. Every day is a test, whether we are mature enough to use our own personal influence for a common good. --- The Logic underneath The following is a very succinct overview of the multidisciplinary foundation that this paradigm and the related change methodology draw upon. When our soul, heart, mind, and body are aligned we enter a state of inner peace, from which the harmonization of our relationships with others flows effortless. Understanding the direct and indirect impact that the interplay of aspirations, emotions, thoughts, and sensations has on ourselves, and on our environment, allows us to systematically develop the influence that we need. Instead of being influenced, we influence. The results of such multidisciplinary cognizance are to our own benefit and can be turned to the benefit others. --- Change from the Inside out Neuroimaging shows the physiological construct that connects thoughts, emotions, and physical feelings within shared neural networks. 4 There is a functional architecture of diverse mental states that were previously seen as intangible. The brain perceives our mental states through situated conceptualizations, which combine three sources of stimulation . The first is sensory stimulation from the world outside the skin. Exteroceptive sensory signals come from light, vibrations, chemicals, sound, etc. The second type of stimulation comes from interoceptive sensory signals within the body The third source of stimulation is prior experience, also referred to as memory or category knowledge, that the brain makes available in part by the re-activation of sensory and motor neurons. . These three sources-sensations from the world, sensations from the body, and prior experience, are continually available. The brain networks that process them can be thought of as the basic ingredients that form all mental processes. Whatever we experience as emotion, cognition, or perception results from the combination and weighting of these ingredients. In contrast to previous beliefs, recent studies show that there is not one network for each emotion or even for the experience of emotion versus cognition. Rather, they are all part of the same network, a living spiderweb that connects every aspect of our inner and outer experience of that state called reality . Humans have evolved to decode their environment . We unconsciously analyze what is happening long before cognitive judgment sets in. Built into the hardware of our body and brain, this intricate mechanism allows us to sense approaching events that would otherwise evade our awareness ; alerting us to patterns in our environment that are so subtle that we cannot consciously detect them. The resulting 'gut instinct' is crucial for survival, but fallible. The brain's ability for pattern recognition and pattern identification may trigger suspicion of unfamiliar things or cause us to be overly reactive to people who remind us of someone . The interpretation we make of an event depends on our prevailing mind-set, which is influenced by both our past experiences, including upbringing and education, and current exposure to influences like opinions and social currents. During the first months of a child's life only the right frontal lobe is active. It is this brain component that will eventually specialize in visual-spatial perception, creativity, and emotions. During the initial phase of life, we experience and express our emotions directly because the inhibition of the left frontal lobe is not yet coming into play. Our internal filter mechanisms are still being established. A baby cries when it is unhappy and laughs when its happy, without a detour via the learned 'right/wrong' department of social expectation. As we grow up, our being shifts attention from the world to the self. Gradually, we are not just reacting to the world, but proactively acting in it. Daniel Kahneman's explanation of two parallel, yet complementary thought systems helps us understand how to use intuition with care . "System 1" is fast, instinctive, and emotional, used in situations requiring fast reaction because we face immediate danger. "System 2" is slower, more deliberative, and more logical. While the first is automatic, the second needs concentration and agency to process thoughts. It is part of the conscious self, which makes choices, has reasons, and holds beliefs. In the same way in which the intake and analyses of sensorial inputs happens via a spiderweb that embraces the whole body, the brain is far more versatile than presumed for a long time. . The right/left separation that was long considered as a valid schematization of the brain's operating system is only part of the answer. Recent evidence is consistent with a psychological constructionist approach of the mind: a set of interacting brain regions commonly involved in basic psychological operations of both an emotional and non-emotional nature are active during emotion experience and perception across a range of discrete emotion categories. 5 . Furthermore, the brain can change its own structure and function in response to mental experience, due to neuroplasticity . The brain's capacities are dynamic and trainable: "The brain is a far more open system than we ever imagined, and nature has gone very far to help us perceive and take in the world around us. It has given us a brain that survives in a changing world by changing itself." While advantageous in some cases, neuroplasticity also has a downside when it comes to the efficiency of opioids for chronic pain treatments. As the plastic brain's own opioid receptors grow saturated, it produces new receptors which are less sensitive to the medication, rendering the patient more and more dependent on higher and higher doses. However, once understood, neuroplasticity can serve to steer a patient away from opioid-induced brain sensitivity. . --- Change from the Outside in Action and attitude shape each other, and hereby our emotions. When we aspire to be kind, generous, patient or a good listener; than we can start to induce this character-trait long before it feels like a natural manifestation of our character. The brain is our best friend when it comes to the design and implementation of Who we want to be. The outside-in change dynamic works in smaller and larger ways. On the one hand bodily posture impacts our physical, mental, and emotional status. It influences our mood, memory, behaviour, and stress levels. It not only eases the symptoms of depression but lessens self-focus . Physiologically speaking a physical pose that reflects an attitude of powerupright, square shoulders, and head up sends a signal to the brain; a neural impulse which turns into an actual, physiological response that boosts brainpower. Furthermore, posture affects hormone levels-decreasing cortisol and increasing testosterone, the latter being associated with self-confidence . On the other hand, our action impacts our experiences and memories which eventually reshapes our mindset; both metaphorically and practically speaking. The best way to become part of social change is to be proactive, plunging into new projects and activities, interacting with very different kinds of people, and experimenting with unfamiliar ways of getting things done . The traditionally assumed logical sequence-think, then act-is often reversed in a personal change process. Paradoxically, we only increase our self-knowledge in the process of making changes. Priming new habits can begin with actions that are performed consciously, even if the underlying motivation is not intuitive. Gradually, the resulting experiences will result in new habit patterns in the mind. Especially in times of transition and uncertainty, thinking, and introspection may follow physical experimentationnot only vice versa. Transformation involves action, which is likely to cause discomfort if the intended change requires the individual to move out of his/her comfort zone. Actually, it is only outside of this zone's border that personal change occurs. As these new unacquainted behaviors are performed repeatedly, they induce changes in the physical brain circuitry thanks to neuroplasticity , which makes them ever more permanent until they feel 'normal'. Social norms, or mores, which are the unwritten rules of behavior considered acceptable in a group or society, result from the interplay between beliefs and behavior, between individuals and larger communities . In the same way that poverty and violence are condoned in some parts of the world, avoiding and addressing these issues individually and collectively can become a new norm. Humans are hardwired to cooperate, and whatever one does for others has benefits in both directions, for the one who acts and the one who's acted for. Moreover, benefits of pro-social action occur on four levels. The very act of giving back to the community boosts a person's happiness, health, and sense of physical well-being . Beyond benefit for the one who acts and the one who is acted for, others who witness altruistic acts experience renewed hope, appeasement, and the desire to take similar action . From such an expanding attitude of kindness and care among individuals, society overall benefits as the occurrence and acceptability of inequality and deprivation shrink. --- Applying the POZE Paradigm This section offers a way for individuals and institutions to apply POZE in their, practice and activities. The previous section covered the logic that underpins the POZE paradigm. The following pages provide an overview of its application. Having established WHAT it is and WHY it works, we will briefly look at HOW four approaches use the posited principles in the pursuit of clearly defined goalsthe empowerment of individuals , the transformation of institutional culture in the non-profit sector and a shift of leadership perspective beyond influence to inspiration and the expansion of influence to build social good at scale . Each approach is anchored in one particular dimension, yet they operate on the interplay of all four dimensions. While distinct in their scope, with differing prime audiences, each approach is anchored in the same understanding that individuals have the power to change their own destiny and make a difference in the lives of others. This is irrespective of age, education, or socio-economic status. The paradigm presented in this book is grounded in the firm belief that we can, and must, be the change we want. Looking at the multiple dimensions that shape human existence it appears that their continued interplay has influence on 1) the evolution that occurs inside of each dimension, both in the individual sphere ; and collectively ; and on 2) the course of action that derives from the combined effect of this double four-dimensional dynamic. --- A Brief Overview Purpose for Power gives individuals tools to identify and pursue meaning. Connecting to purpose enables individuals to unlock their inherent power to overcome challenges and thrive despite these challenges. Primary audiences and beneficiaries are aid workers, young people, the elderly, teachers, and social workers. Central entry points are school curricula, parental education programs, retirement residences, and employee well-being programs. It is anchored in the soul. To trigger the turn from vicious to virtuous Purpose for Power consists of a fourtrack approach which combines theory and praxis: 1) Training of caregivers in selfawareness, emotional intelligence, stress management and personal leadership. Participants get an understanding of the science underpinning the approach and experience its application first-hand. 2) Design of a curriculum with and by these participants that is in line with the needs of their audiences and the context of implementation. 3) Execution of the curriculum, accompanied by ongoing monitoring to facilitate adjustment in line with arising needs, followed by the evaluation of mile-stone components to learn from experience, and allow for refinement over time. 4) Coaching on the job and peer-topeer support accompany participants while they apply their new expertise. Compassion for Change offers an approach for institutions that aim to reignite passion and value awareness among their staff. The result is improved staff well-being, motivation, and performance, which go hand in hand with enhanced institutional impact and reputation because staff members practice the principles and values they preach externally. C4C helps build a bridge between aspirations and mandate, harmonizing individual and institutional missions. Such harmonization is indispensable for non-profit organizations that seek to raise public enthusiasm towards a social cause. It is anchored in the heart. Humanitarian and development organizations must practice what they preach. Those whose mandate it is to make the world a better place must embody their mission values, individually and collectively, internally and externally. This attitude toward being change is anchored in the self-understanding and behaviour of staff. Whether in the context of humanitarian action, development, or local non-profit mandates, Compassion for Change serves to reconnect staff with their personal aspiration for life, and through these aspirations to connect with the mission and values of their employer. C4C contributes to a transformation of institutional culture by reigniting passion and valuing self-awareness among staff. It nurtures a sense of purpose, belonging, and overall wellbeing; engaging everyone, from frontline fieldworkers to those at headquarters, because in order to effectively help others, every employee must be first able to help themselves. Influence for Impact systematically uses and addresses human aspirations, emotions, thoughts, and sensations to induce desire and readiness for change among individuals and the wider public. i4i supports the design of communication and advocacy efforts that assist and guide audiences through the process of understanding a situation to having a personalized feeling about the issue at hand to caring enough about this matter to act and change the status quo. It is anchored in the body, which is the only interface between our internal and external reality. Influence for Impact offers practical tools to use the mechanics of human decisionmaking to drive prosocial behavior. Based on research and empirical data it promotes changes in existing decision-making architectures, and offers support for the design of new, socially inclusive ones. Playing along the 'Scale of influence' i4i uses different tools for distinct stages of the decision-making process. It combines neutral and intentional communication, addressing intellect and emotions. Since the subconsciousness, and prevailing environment, impact individual decisions, these factors are analyzed and systematically influenced . Ultimately i4i is anchored in the understanding that individuals are inspired to give their best self if they are exposed to people who are authentic because their beliefs, words and behavior are in synch . i4i nudges decisions that are in the interest of the performer and his environment, boosts the performers ability to maintain this behavior and helps to establish institutional structures to facilitate the repetition of these new behaviors overtime. By combining short-time change at the individual level with long-term institutional transformation i4i serves a gradual formation of new behavior patterns that eventually result in new neural pathways in the individual's brain, which makes them permanent habits. And by investing in institutional decisionmaking architectures groups of people undergo this behavior and brain change, which eventually creates new social norms as the new socially inclusive behavior is practiced over time by a large group of people. Primary audiences are 'decision makers', who live the consequences of their decisions , and 'decision takers', whose decisions shape the lives of others, but not necessarily their own . Honesty for Humility brings everything together in a framework of authentic leadership. It offers guidance to accompany the process of unveiling the best version of each individual. Honest introspection is the central pillar from which everything else flows naturally. Therefore, while seeking to be useful along the way, H4H acknowledges that the prime step towards leadership must be taken alone by the individual who is ready. One can indicate the path to the bridge, but not carry the passenger over the river. It is anchored in the mind. Finding and revealing our best self is not about adding more layers, but about removing the existing ones; to uncover what is waiting underneath. The H4H interview is structured around the four interrelated dimensions of the POZE paradigm which looks at human existence as a result of four dimensions -soul, heart, mind and body, which find their expression as aspirations, emotions, thoughts and sensations. Summarized as Purpose, Om, Zoom, Experience. These four dimensions correspond to the four arenas in which we invest our energy -spiritual development , relationships , learning and effort , hobbies and recreation . When analyzing our personal past , present and future before the backdrop of perpetrating universal values, a common thread emerges which connects the dots of our life. --- Perspectives COVID-19 engulfs all sectors. A sense of doomsday lingers at the back of everyone's mind, mixed with a sense of uncertainty and unease. We want our life back, but the society that we left behind is gone. . The reality pre-COVID is no longer; and there is no point trying to resuscitate it. The ongoing crisis is a tragedy, and an amazing opportunity. COVID-19 unraveled our routines. Never had millions of people around the World an experience that was the same at the same time. Furthermore, while for millions the Pandemic has further aggravated an already harsh struggle for economic survival, for others, lockdowns and physical distancing resulted in empty time. Shaking up our habits, COVID -19 pushed us Fig. 2 Everything is connected, from the inside out and from the outside in. Power that is rooted in purpose leads to change that is sustainable and has impact, when the agent of change is driven by compassion and thereby able to genuinely connect with others. Change is sustainable when it comes from a place of personal honesty and humility. When passion, compassion, and honesty are rooted in genuine aspirations, the agents of change have influence because their being and behavior inspire. Being authentic s/he can build change that has impact. This type of social impact engenders in others the desire for purpose, and the quest for their own best self into a virgin space to contemplate and react to the unfolding situation with acute awareness, rather than acquired routines. It offered an opening for POZE. At the macro-level, we are facing a systemic social paradox today. . It derives from the combination of a Virus that objectively speaking puts everyone at risk of getting sick and die, and of a layer of massively condoned inequities that have been lingering for centuries. This amalgamation of past and present leads to a status quo whereby the exposure to COVID-19, and the impact on the individual, vary dramatically. The future is haunted by factors that were unsolved and inherent to our social system. At the meso-level, the Pandemic that afflicts us today has started in a wet market where animals were kept for consumption; catering to our meat-heavy consumption habit. This lifestyle is not conducive to short-term health, nor sustainable for the future of our Planet. . At the micro-level, the social toll that derives from inequity, isolation, emptiness, and depression had put its roots in our lifestyle long before the onset of COVID-19. If everything that happens around us has a counterpart inside, then whatever change we want to trigger outside starts with the journey of personal transformation that individuals, voluntarily, undertake inside. Looking at the status quo through the prism of the POZE paradigm offers one part of the answer. But paradigms, philosophies, and propositions serve only if they are translated into practice. To not just survive 2020 but thrive in the coming years we must acknowledge that none of us is alone in this; and act accordingly. Our individual wellbeing depends in the long-term on action that we take for the wellbeing of others in the short term. It is a win-win-win-win: If our responsible action helps to reduce contagion, both others and ourselves benefit; the risk is reduced , then societies can return to a normal operating mode ; furthermore, those who take action for the sake of others benefit from the alignment of their personal values, aspirations and behavior, which is a condition of sustainable subjective wellbeing . The combination of enhanced wellbeing for the person who takes action and for the person for whom this action is taken for , is further expanded by the fact that others who observe the behavior of selfless action get inspired to do the same . The snowball effect of the pay-it-forward dynamic is triggered. 6 The longstanding paradigm of homo homini lupus est has served for centuries as an unspoken justification for ego-centric behavior; a given that was condoned as unavoidable. Today's scenario may serve to build a new understanding of shared interest. The prevailing situations engulfs all of us indiscriminately; whatever separation existed before COVID-19 took over has become superficial. 6 Various studies have shown that happiness and ideas can spread from person to person. Experiments have shown that beyond such abstract aspects of human experience concrete behavior patterns, such as altruism and cheating can be triggered, with ripple effects, as well. While in the past it was not always clear if people were actually influencing their peers, if all the people that behaved similarly were influenced by the same environments , or if they just choose to assemble with others who think and behave like they do. Based on randomly grouped players the last two explanations were excluded in a 2009 study by Fowler and Christakis. The results suggest that people tend to mimic the actions of those they played with. They could be directly imitating the actions of other players, or they could be looking out for cues that tell them the 'right' or 'normal' way of behaving. Whether it's specific actions or social norms that are spreading, the result is the samea ripple effect that causes groups of people to act in similar ways An attitude of homo homini lux est is needed and at reach. The previously enshrined normality is gone for good. The crisis has opened space to think beyond the conventional line that was previously taken as the horizon. Maybe the plate is bigger than we thought, with space to accommodate not just crumbs but cake for everyone. The size of plate and cake depends on our willingness, our choice, to seize the opportunity. Starting with individual decisions we can generate a new normality where solidarity is the standard, and untamed self-interest shunned. This shift starts with the intellectual understanding that we are physically part of an interconnected global community . This point of departure activates a desire to get up and involved. Connection generates compassion because it is anchored in our personal aspiration for purpose . Taken together this package enables the mind to envision creative solutions that explode the known. Changing the world may sound abstract, but it is de facto a very real possibility that involves every single member of 'Society'. Every meso-entity is constituted of myriads of micro-entities and depending on their size and nature it may entail multiple meso-entities . 7 Independently of their size and complexity the entities that are part of the Meso-dimension operate along the same principle of interconnected dimensionality as does the smallest unit in its compositionthe human being. How an institution evolves is determined by the action and interplay of the particles that constitute it. Simply saidsince an institution is made of 7 While the meso-dimension is sub-national, certain institutions at the meso-level have counterparts at supranational level . This double nature illustrates the dimensions are inseparable and the myriad interactions of elements across dimensions. A similar double-sized nature marks the meta-dimension which entails on the one hand supra-national institutions such as the United Nations, and on the other hand the sum of all entities and non-anthropocentric spheres such as Nature. Fig. 3 Everything is connected, from the inside out and from the outside in. The individual is the smallest component of a global system, and part of various 'families' which result from biological, social, or professional constellations. Individuals and families/communities form society, within the contours of nation states, economies, and cultures. These three dimensions are part of Planet Earth, coexisting with nature. Whatever occurs in one dimension has consequences on the others. Individuals influence the communities they are part of, and hereby society, and the planet. Whereas changes at this level impact the dynamics of society and the families and individuals that it is made of individuals, its institutional identity and organizational operation derive from the identity and action of the people who work in it. Since individuals and institutions shape the macro-dimension, and are major components of the meta-dimension, the post-COVID-19 Society hinges on the compass that sets the course within these two spheres of life. --- The Body Is our Interface with the World As the present crisis unfolds this physical crossing-point between our inside and the outside, is becoming a source of acute anxiety for many. From a door that allows us to share and connect, it has been gradually morphing into a barrier. We can transform our physical interface from a source of fear into a well of hope; for ourselves and others. Cooperation may appear to go against our ingrained instinct of purveying first to our own needs. However, supporting others in an effort of sharing is part of our DNA. It is the reason why humankind has reached the present stage of evolution. . Replacing interpersonal exchanges with physical, mental, and emotional self-isolation is not a sustainable choice. Seeking refuge in our comfort zone, by not merely physically retiring to our own four walls, but mentally and emotionally retracting to the opinions and company of closest kin; those whom we are familiar and comfortable with, is tempting. It may feel like the prime choice in a strange scenario of sweltering uncertainty. We do not have that luxury. Preparing the Society that we want to live in afterwards, personally and collectively, must start now, amid the crises. A life that is worth living is another way to frame the concept of quality of life. Beyond the physical aspects of food, water, safety, health care, education, and shelterwhich are the basic minimum that must be ensured for every being on this Planet, we require meaning to find fulfillment . And fulfillment is a central ingredient of quality of life. Purpose is the compass of life. It conditions our happiness, individually and collectively. . COVID-19 has brought to light that everything can change from one day to the next. However, building on the four-dimensional paradigm mentioned above, four principles emerge as untouched by the present scenario. These are the central pillars of a post-COVID-19 society that is worth living in. Purpose conditions human completion, 1) The quest for Purpose is the central driver of human life. 2) Compassion for oneself is a transition to compassion for others,8 3) Honesty fosters a type of candid creation that is free from wishful thinking, and thus innovation incorporated, 4) Influence on the circumstances that determine our existence derives from the understanding of their interplay; and it optimizes the cooperative dynamics that underpin them. The interaction of the four internal and the four external dimensions shape our individual and collective existence.9 Optimizing it is beneficial to each of us. POZE hopes to help with this optimization to enable everyone to lead a full, safe, happy, and enjoyable life. --- Compliance with Ethical Standards Conflict of Interest The authors declare that they have no conflict of interest. On behalf of all authors, the corresponding author states that there is no conflict of interest.

After a brief overview of the author's journey as a humanitarian and researcher, this article offers an introduction in the why, how, and what of a new multidisciplinary paradigm to understand (and improve) human behavior at the individual and collective levels called POZE. The logic of POZE underpins five books that appear at Palgrave/Springer in 2020/21. It is based on the understanding that human existence results from four dimensions, soul, heart, mind, and body, which find their expression in aspirations, emotions, thoughts, and sensations. Through their four-dimensionality individuals are symmetrical to the four dimensions that shape the society, which they are part of. Individuals are the micro entity of a four-dimensional collective reality that encompasses communities and institutions in the meso-dimension, and countries and economies in the macro-dimension. Altogether micro, meso and macro are integral parts of the meta dimension, Planet Earth; the latter also includes non-anthropocentric aspects such as Nature. POZE provides insights about the multiple dynamics that shape our individual and collective experience. Moreover, it provides practical guidance to optimize the interplay between them. As a result of this understanding, it posits that change is possible. Moving towards a fair inclusive world, characterized by a life of quality for everyone 1) is at reach; 2) is achievable; 3) involves everyone as both a right-holder and duty-bearer; and 4) is to the benefit of everyone. POZE has four meanings: it i) translates as 'inner peace' from Haitian Creole, country where the dynamic began in 2017; ii) is an acronym that encompasses the four core concepts of the paradigm (Purpose, Om, Zoom, Expression); iii) is a representation of the four outcomes of the logic (Perspective, Optimization, Zenith, Exposure); finally it iv) stands for an exercise to nurture inner peace daily (Pause, Observe, Zoom in, Experience). These will be explored further in the article.

Cultural, philosophical and legal aspects of volunteering... the need to adapt such interventions and models of public volunteers to the local context. It is also emphasised that despite success in implementing interventions, volunteers experienced exhaustion and needed additional motivation and substantial support. A. Baimbetova et al. examined the specifics of volunteer activities in the tourism industry of the Republic of Kazakhstan, which is in the stage of formation and integration. The researchers identified a low level of motivation in this sphere of volunteer activity. To address existing problems of volunteer motivation, the following methods were proposed: creating volunteer infrastructure at the regional level; financial support for volunteer organizations; implementation of educational events for volunteers; creating a legal environment that mitigates legislative barriers for volunteers. M.N. Khushnazarova suggests a step-by-step approach to preparing graduate students in social work for the implementation of Uzbekistan's state policy in the field of volunteering. She highlights three levels of educational operations: the information level -forming knowledge about the nature of volunteering in solving important societal problems; the relationship level -actualising volunteering as a positive phenomenon in society; the behaviour level -attracting and encouraging students to engage in volunteer activities. Thus, the scientific discourse on volunteer activities in Kyrgyzstan has low intensity. Given this state of the issue, there is a need to fill this research field with a relevant and comprehensive study that could reveal the essential aspects of volunteering in Kyrgyzstan. Based on this, the purpose of the study is to determine the motivational and operational components of volunteer activity in Kyrgyzstan, considering historical foundations, contemporary realities, and potential development prospects. To achieve this purpose, the following tasks were set: to record the cultural and religious paradigms of volunteer activities in Kyrgyzstan; identify contemporary challenges and problems faced by volunteers and volunteer organizations in Kyrgyzstan; highlight prospective vectors for the development of volunteering in Kyrgyz society. --- Introduction The multifaceted and multi-aspect nature of volunteer activity in Kyrgyz society stimulates research aimed at exploring both cultural foundations and modern determinants and predictive constructs capable of anticipating the future state of this sphere of human activity. The relevance of a comprehensive analysis of volunteer activities in Kyrgyzstan is associated with the epistemological need to identify cross-cultural and unique national features of volunteering in this country. This is necessary, primarily, for understanding the overall picture and architecture of volunteering in Kyrgyzstan. S. Dzhuraev notes that during the pandemic, not only did the vulnerability of the state become apparent, but also the remarkable resilience of society as a whole. Even in the absence of medical personnel and medicines in hospitals, thousands of volunteers stood up to defend society. These volunteers were diverse groups of people, including medical students, businessmen, and ordinary citizens. The results of the study identify three key roles of volunteers at different stages of the pandemic. In the initial period of the crisis, the volunteer movement was growing to provide support to the most vulnerable socio-economic groups. I.A. Akhmetova et al. analysed the historical roots of volunteering in Kazakhstan. They note that volunteering in the Kazakh steppe has formed and developed over many centuries, combining national identity with sociocultural characteristics. Volunteering in the Kazakh steppe has its own path. By exploring the formation and development of this sphere of human activity, researchers identified three historical sources of volunteering in Kazakhstan: the development of Islamic culture in the Kazakh steppe as a voluntary institution; tribal aid in traditional Kazakh society as a social institution; the transmission of volunteering ideas by Kazakh educators. A study conducted by A. Kireyeva et al. analysed the influence of women volunteers on the process of government management in palliative care for patients in Kazakhstan. Their study included interviews with two groups of respondents: volunteers and employees of medical institutions and charitable organizations. The interview results showed that women volunteers play a key role as intermediaries between the government administration and the palliative care system. The contribution of these women volunteers is associated with providing financial support, organising training and workshops for doctors, especially in the field of oncology, providing additional beds for patients, and consultations. R. Yorick et al. , analysed the success of the project Tajikistan Health and Nutrition Activity , which was funded by the US Agency for International Development "Food for the Future". Within this project, 1370 volunteers in 500 rural communities were trained to improve the nutrition of children, pregnant women, and lactating mothers. The results of the study indicate the success of joint activities in the field of agriculture and health in improving the nutrition of children, and these models can be applied in other contexts. However, the researchers express concerns about factors for effective organisation of volunteer activities and addressing social and legal challenges in the future. The study contains valuable information for government institutions related to volunteering and will be useful for the development of high-quality state policy in this area L. Ji et al. known as "aiyldyk kenesh." Furthermore, much attention was paid to the personal values of the volunteers in the form of beliefs and ideals that inspire them. The use of a praxeological approach in researching the cultural-philosophical aspects of volunteering in Kyrgyzstan was valuable because this approach focuses on the practices and experiences of volunteers. The emphasis was primarily on specific types of activities that volunteers perform in Kyrgyzstan. It explored which practices are most popular and how they interact with the cultural and philosophical features of the country. In addition, the experience of volunteering was considered. An analysis was conducted to understand what kind of experience individuals gain through volunteering and how it influences personal and professional development. The theoretical part of the study is also supported by general scientific methods: analysis, synthesis, and comparison. The joint use of analysis and synthesis allowed for breaking down complex phenomena into components and then assembling them back into a comprehensive understanding. The heuristic potential of this methodology lay in the ability to dissect various aspects of volunteering into parts and then synthesise these parts to understand their interconnection. Comparative analysis allowed for juxtaposing volunteering in Kyrgyzstan with the experience of other countries and regions to identify common trends and features. This method helped understand how cultural and philosophical aspects of volunteering differ or converge in different contexts. As a basis for the empirical part of the study, a survey method was used. The sample consisted of 284 respondents. The survey was conducted throughout the year, from October 2022 to October 2023. This study aligned with the ethical principles of research, including anonymity, confidentiality, and beneficence. Ethical approval of the study was obtained from the Ethics Commission of the Kyrgyz National University named after Jusup Balasagyn. Residents of Kyrgyzstan who were engaged in volunteering on a permanent or partial basis were interviewed. The respondents were selected using the snowball sampling technique. This is due to the specific object of the study, which included respondents with a special field of activity. The questionnaire was distributed in the format of a Google Form. The questionnaire had both closed and open-ended questions . An open-ended question. --- Table 1. Example of questionnaire questions Cultural, philosophical and legal aspects of volunteering... The processing of the obtained results assumed qualitative and quantitative analysis. Closed questions with predetermined answer options were processed quantitatively, involving the calculation of statistical indicators such as percentages and correlations. Answers to open-ended questions required high-quality processing. Coding and content analysis were used to identify themes and images of respondents' statements. --- Results --- Modern socio-cultural features of Kyrgyzstan Before documenting the cultural-philosophical and religious paradigms of volunteering in Kyrgyzstan, it is necessary to analytically outline the sociocultural background of the country. The general contemporary state of the sociocultural background and the trends influencing it should be analysed. Modern Central Asia, including Kyrgyzstan, is a former Soviet space where unique processes of transformation are taking place. This uniqueness is influenced by various factors shaping contemporary transformation processes . The culture of Central Asian peoples is characterised by the influence of the traditions of the indigenous ethnic group, Islamic religion, residual phenomena of the Soviet era, and processes of globalisation . These are four fundamental forces that have a significant impact on the sociocultural background not only of Kyrgyzstan but also of other countries in Central Asia. In Source: compiled by the authors recent years, Kyrgyzstan has witnessed an increase in the popularity of conservative discourses that do not adhere to liberal views. Non-liberal social activists actively interact with the Kyrgyz-speaking population and promote traditional values, combining them with religious teachings. This evident trend can be interpreted as a manifestation of growing re-traditionalization and anti-Western orientation, which have become an integral part of the Soviet worldview and ideological system . Throughout Central Asia, there is a tendency toward strengthening authoritarian regimes, leading to a decreased interest in creating political and legal structures typically considered foundational for pluralism . One characteristic feature of traditional influence on Kyrgyz society is the transmission of specific cultural codes using verbal means. The values and culture of the Kyrgyz people are transmitted and preserved from generation to generation through verbal expressions and images . An example of such verbal tradition in Kyrgyzstan is the word "Uyat," widely used in the country. It is often uttered regarding children to curb inappropriate behaviour. This is an essential element of interpersonal relationships that structure everyday life, causing discomfort in conversation and establishing boundaries of decency. "Uyat" is often translated as "shame". This practice of shame in Kyrgyzstan contributes to maintaining social control . Kyrgyzstan is also experiencing the process of Islamisation, and this process is not yet complete. People continue to educate themselves and engage in discussions, while the practical implementation of Islamic teachings remains at an early stage. Discussions about how-to live-in accordance with Islamic beliefs have intensified due to the growing interest in Islam and a lack of prior knowledge about the religion . The general situation in Kyrgyzstan reflects the social and spiritual crisis. The social crisis in the collective consciousness emphasises the critical nature of the situation and creates a sense of overcoming barriers hindering society's progress. On the other hand, the spiritual crisis indicates the breakdown of the cultural foundations of society, which has encountered a development deadlock. Part of society seeks to return to its roots and fundamental values, while simultaneously attempting to find ways of adaptation in the conditions of globalisation to restore the integrity of its existence . Thus, the modern sociocultural background in Kyrgyzstan is portrayed as a "field of struggle and interaction" between traditional and religious cultural postulates and values rooted in processes of globalisation and post-Soviet transformation. --- Motivational structure of volunteer activity in Kyrgyzstan and the influence of cultural factors To further specify the issues related to volunteer activity in Kyrgyzstan, a survey involving actual volunteers was conducted. The primary focus was on identifying the cultural and philosophical motives of volunteer activities. In other words, an attempt was made to find the worldview determinants that define the value and motivational components of volunteer work. The study primarily concentrated on cultural postulates related to the sociocultural background in Kyrgyzstan. The primary question was related to the intensity of volunteer activity of the respondents to understand the level of their involvement in this activity . More than half of the respondents are regularly engaged in volunteer activities. This indicates that the object of the study is very closely related to this field. Therefore, there is an opportunity to get clearer and deeper data on volunteer activities in Kyrgyzstan, using the responses of its active participants. The first important issue directly related to the axiological component of volunteer activity in Kyrgyzstan was the measurement of thematic interest in volunteer activity. The interviewed volunteers were asked a question concerning their personal interests in volunteering: respondents chose which events or organisations of volunteer activity they were most interested in. Almost one-third of respondents are interested in educational programmes -29.9%. Primarily, these projects support the upbringing of children and help the school infrastructure. This is the dominant interest among respondents. In second place among the interests is the organisation of cultural events and events. It can be festivals, exhibitions, and concerts. This area of interest was chosen by 22.5% of respondents. Approximately one-tenth of respondents chose humanitarian interests: assistance to the needy , medical care , and family support -10.6%, 12.3% and 10.2%, respectively. Such interests as environmental projects -7% and social rehabilitation -3.3% did not pass the ten per cent barrier. Thus, the priority of volunteers in Kyrgyzstan is educational and cultural projects. At the same time, social projects are of secondary value. Respondents were asked what specific factors inspire them to volunteer. Almost half of the respondents indicated a social motive for their volunteer activity -43.9%. The social motive refers to altruism as one of the important components of the worldview system of volunteers. It was essentially a desire to improve society and contribute to it. Personal interests were in second place among motivational factors -15.3%. Respondents who chose this option were attracted by the satisfaction of their personal interests and hobbies. In 12.4% of respondents, the choice of volunteer activity was influenced by religious attitudes. For them, faith and the values associated with it are the motivational basis of volunteer activity. Only 7.8% of respondents stated that they were driven by traditional values, namely, the protection and promotion of the cultural traditions and customs of the Kyrgyz people. Factors of professional development and emotional satisfaction did not pass the ten percent barrier, at 7% and 8.1%, respectively. For a clearer assessment of the influence of traditional values and religious beliefs on volunteering, respondents were asked about the motives that determine their choice of volunteer activities. It was noted that internal personal convictions, unrelated to cultural or religious content, are the primary factor for respondents, standing at 57%. Only 15.9% of respondents indicated that their religious beliefs and obligations could influence the choice of volunteer activities. Traditions and customs of Kyrgyzstan have even less influence on volunteers -8.8%. Thus, there is no basis to claim that religious beliefs and traditional values significantly impact volunteer activities in Kyrgyzstan. The insignificant role of religious attitudes is confirmed by another question. Respondents were asked about the role of religion and religious organisations in volunteer activities in Kyrgyzstan. Almost half of the respondents believe that religion has a minimal impact on volunteer activity -46.8%. Approximately one-third think that religion has a strong or moderate influence -28.2%. One-fifth of respondents indicated that religion has no influence -21. 5%. An open-ended question was also asked, which concerns specific aspects of religion that can influence volunteer activities. It should be indicated beforehand that only a third of the respondents answered this question. Through categorical classification of responses, specific thematic lines were identified and ranked by popularity. Firstly, respondents indicated that religious attitudes could inspire volunteering. They indicated moral values that correlate with volunteer activity -compassion, kindness, social justice. The second most represented thematic category was related to charity. In Islam, the principle of "Sadaqah" encourages people to charity. The third most represented thematic category is the principles of education and cognition. Respondents indicated that religion emphasises the importance of education, which can encourage volunteering in educational projects. As for the influence of the traditional values of the Kyrgyz people on volunteer activities, approximately half of the respondents believe that there is no influence -47.2%. Approximately a quarter of respondents indicate that there is only a minimal impact -26.4%. Only less than one-fifth of respondents indicated that traditions and customs have a strong or moderate influence -15.8%. Thus, the influence of traditions and customs is even lower than the religious influence on volunteer activity in Kyrgyzstan. For a more complete understanding of the real impact of traditional values on volunteering in Kyrgyzstan, an open question was asked in which respondents could offer their unique answers. The analysis of the responses showed that, according to the volunteers, there are three thematic aspects that can be associated with volunteer activity. Firstly, the idea of preserving cultural heritage. Respondents believe that volunteer activities can be aimed at preserving and promoting cultural traditions and national heritage. Secondly, festive events. Various traditional holidays and events can become a breeding ground for various volunteer practices. Third, support for local communities. Here, respondents pointed to the indigenous traditions of mutual assistance and solidarity in Kyrgyz society, which can contribute to volunteer activity. Thus, it is evident that traditional values and religious attitudes do not significantly affect volunteer activity in Kyrgyzstan. Factors that have a rational basis come to the fore, which indicates the predominance of a rather modern vision of volunteer activity and a greater emphasis on modernity. However, it is important to note that traditional and religious aspects can still play a role in volunteering, especially in local communities and for certain groups of people. However, at the moment, rational and modern factors, such as financial support and professional development, seem to be more of a priority for most respondents. This may indicate that volunteering in Kyrgyzstan is becoming a more professionalised and organised type of activity, which may contribute to its more effective impact on social changes and the development of society. --- Modern challenges and problems of volunteeringin Kyrgyzstan Respondents were also asked a series of questions related to the contemporary challenges facing volunteer activities in Kyrgyzstan. The first question addressed the most pressing issues volunteers encounter in Kyrgyzstan. The lack of funding and resources was mentioned as the primary issue, at 29.9%. Approximately one-fifth of respondents indicated that the main problem is the difficulty in organising volunteer projects -22.5%. Slightly more than one-tenth of respondents identified the main problem as the challenge of collaborating with government and non-government organisations, at 12.7%. Issues that did not surpass the ten per cent threshold included a lack of training and development of volunteer skills , the absence of a legal framework for volunteer activities , a lack of information support for volunteers , conflicts and misunderstandings among volunteers , and a lack of recognition and encouragement of volunteers in society . In addition, respondents were asked about the problems faced by volunteer organisations. In the first place, respondents indicated financial difficulties and dependence on grants -26.4%. In second place is the lack of professional management and resources. This option was chosen by 18.3% of respondents. In third place is the lack of modern technologies and information infrastructure -16.9%. Only 11.3% of respondents identified the main problem as the difficulties in collaboration with government structures and other non-governmental organisations. Challenges that did not reach the ten per cent threshold included uncertainty in defining priorities and goals , ineffective communication within the organisation , insufficient coordination between volunteer organisations , and difficulty in recruiting and retaining volunteers . Both for individual volunteers and volunteer organisations, financial issues are the top priority in the contemporary stage. An open-ended question was also posed regarding the challenges of Kyrgyzstan's society that volunteers address at the present stage. Categorical analysis of open-ended questions identified seven thematic categories. According L. Ji et al. to respondents, the most priority task of volunteering in Kyrgyzstan is social assistance. It involves helping socially vulnerable segments of the population: the poor, homeless, elderly, and other vulnerable groups. In the second place is education and support for youth. This primarily involves activities aimed at providing educational programmes and consultations. Healthcare and medical care are in third place. Respondents indicated participation in medical programmes. Especially during the COVID-19 pandemic. Less popular challenges for volunteering included the development of local communities, combating discrimination , cultural projects, and environmental initiatives. It should be noted that legal regulation of the volunteer sphere in the Kyrgyz Republic began with the adoption of the Law of the Kyrgyz Republic No. 77 "On Volunteer Activity" . This law regulates various aspects of volunteering, including the prohibition of its use to support political parties, religious organisations, commercial promotion of goods and services, and commercial intermediation. The law also prohibits the creation of volunteer organisations similar to paramilitary groups. This law is part of the national policy on volunteering in Kyrgyzstan. It reflects the desire to develop and regulate the volunteer movement in the country. However, some organisations, such as Amnesty International , have expressed concerns about other legislative changes that could have a negative impact on the work of non-governmental organisations and civil society in general. --- Future prospects of volunteering in Kyrgyzstan As the final task of the study was achieved, respondents were presented with a set of questions regarding the future of volunteer activities in Kyrgyzstan. Primarily, a question was posed concerning the respondents' perception of the future of volunteerism in Kyrgyzstan using the "optimism-pessimism" dichotomy. More than half of the respondents are optimistic about the future of volunteering in Kyrgyzstan -56.4%. Approximately one-fourth is neutral . Only 12.7% of the volunteers who passed the survey are pessimistic about the future of volunteering in their country. To further specify this question for those who are optimistic about the future of volunteerism in Kyrgyzstan, a follow-up question was asked. It was associated with specific vectors of volunteering development in Kyrgyzstan. Almost a third of respondents assume that funding for volunteer organisations will improve in the future -29.6%. Approximately one-fifth believe there will be an increase in state support and recognition of volunteers -19.4%. Forecasts for other vectors were less significant: the creation of platforms for coordination and information exchange among volunteers and organisations ; the development of international cooperation and the exchange of volunteering experiences ; encouraging youth to participate in volunteer activities ; and the development of educational programs and training for volunteers . For a more individualised understanding of perceptions of the future of volunteer activities, respondents were asked an open-ended question that considered their fantasies and visions of the future of this activity in Kyrgyzstan. Based on the responses, five thematic categories were identified. The most common is the image of a developed and powerful volunteer infrastructure. In second place, respondents saw the future of volunteering in Kyrgyzstan with global cooperation. This indicates that the concepts correspond to the globalisation logic of development. In third place, respondents have images associated with innovative technologies in volunteering. Less significant visions of the future include the increased diversity of volunteer activities and strong involvement of youth in this type of activity. Thus, respondents see the future of volunteer activity in Kyrgyzstan optimistically. The vectors of development, according to respondents, are associated with an increase in funding and establishing relations with the state apparatus. In general, respondents expect the strengthening of volunteer infrastructure and global cooperation. Global cooperation and the strengthening of volunteer infrastructure can contribute to the effective organisation of volunteer activities, including the expansion of the sphere of influence and the involvement of more people in volunteer projects. These factors can contribute to the improvement of society and the solution of various social problems in Kyrgyzstan. Thus, respondents consider the future of volunteering in Kyrgyzstan promising and positive, based on optimism and confidence in the possibility of volunteering to make a significant contribution to the development of society. --- Comparative analysis of cultural and legal aspects of volunteering in different geographical regions A striking example of the contrasting cultural foundations of volunteerism can be seen by comparing the United States and China. The USA has a long history of volunteering, which plays an important role in society. Many Americans are actively involved in charitable and volunteer organisations. There are a huge number of volunteer organisations working in various fields, from helping those in need to environmental protection. Individualism and private initiative in volunteering are often welcomed in the USA. Therewith, there is a growing interest in volunteering in China, and young people are actively involved in many projects. The Chinese government also actively encourages and supports volunteering, especially in the field of social services. In China, there are some cultural features that influence volunteering, such as the emphasis on family values and communal initiatives . Thus, volunteer activity in these countries is strongly influenced by fundamental cultural and social paradigms such as individualism and communitarianism . In addition, there is a long history of charity and philanthropy in the United States, and this has an impact on the culture of volunteering. It is generally believed that Western societies are more materialistic compared to other cultures. The results of empirical research show that materialism can coexist with charity. However, it has also been observed that Americans are among the most generous nations, donating their time, money, and efforts to charitable causes . In the United States, volunteer activity is primarily regulated by labour and employment laws. Volunteers are not considered employees under the Fair Labour Standards Act and are therefore not entitled to minimum wage or overtime pay. However, they must be providing services for a non-profit organization or government agency, and their work should not displace paid employees. Additionally, volunteers are generally not covered by workers' compensation laws. The legal framework for volunteerism in the US is largely based on the principle of voluntariness and is aimed at protecting the rights of volunteers and the organizations they serve . In turn, in China has a legal regulation for volunteer activity called the Regulation of Volunteer Service . The regulation aims to protect the lawful rights and interests of volunteers, volunteer service organizations, and the recipients of volunteer services, encourage and regulate volunteer services, develop the field of volunteer services, cultivate and practice the core socialist values, and promote the improvement of society and civilization. The regulation also applies to volunteer service activities and activities related to volunteer services carried out within the mainland territory of the People's Republic of China. Volunteering in Europe is often associated with the promotion of social justice, human rights, liberality, and pluralism. According to the findings of a European study, it was established that macrostructural indicators of civil liberties and the level of social trust are positively correlated with the level of volunteer activity. These results indicate that in countries with higher civil liberties and a level of social trust, the probability of citizens' involvement in volunteer activities is higher. Equality and social trust play an important role in this regard, providing a basis for the development of volunteerism in Europe. The study also highlights that historically inherited institutional features can influence individual volunteering abilities . The cultural diversity of European countries should also be considered. In the course of a study by A. Gil-Lacruz et al. , in European countries where people have a positive attitude toward their friendly contacts, citizens are more likely to participate in social activities, education, and leisure actively. However, in these countries, they are less likely to participate in activities related to social justice, compared to those countries where friendship is less important. The legal regulation of volunteer activity in Europe varies from country to country. Some European countries have launched legislative reform initiatives to create an environment that fosters volunteering. For example, the Act LXXXVIII "On Public Interest Volunteer Activities" in Hungary regulates volunteering for non-profit entities and non-governmental organizations . Similarly, the Framework Law 266/91 "On Volunteering" in Italy prescribes the principles and criteria that regulate the relationship between public agencies and volunteer organizations. In Spain, there is a Law 45/2015 "On Volunteer" that regulates state competences and offers companies, universities, or public administrations the possibility of becoming a target audience for volunteers. The European legal framework on cross-border volunteering also addresses the regulation of volunteering activities, including the definitions of volunteering, volunteerism, and volunteer service. There is a tradition of solidarity within communities in Central Asian countries. Often volunteering can be associated with the support of families and neighbours. An important aspect of traditional Central Asian culture is the "Toy" -a traditional gathering where people gather for joint activities, such as building houses or helping those in need. Unlike Europe and the USA, there is no clear division between public and private spheres in traditional Central Asian culture: birth, death, and marriage are community affairs, not family affairs . This traditional culture of solidarity and community also contributes to the development of sustainable communities where people are ready to help each other in difficult moments. This may include support in the event of natural disasters, assistance to families during a disaster, and joint efforts in education and health. Such traditions and values can serve as a basis for the development of volunteerism and civic engagement, and they can be important resources for solving social problems and strengthening society in Central Asia. The legal regulation of volunteer activity in Central Asia has been a topic of increasing importance. In Kazakhstan, for example, the country adopted a law on volunteer activity in 2016, enshrining legal regulation related to the sphere of volunteering . However, the development of robust, independent civil societies and NGOs in Central Asia has faced challenges, with concerns about new regulations that could further restrict and criminalize their activities. Despite these challenges, there have been initiatives to promote and recognize volunteerism in Central Asia, such as the distribution of volunteer awards and the convening of the first Central Asian Volunteers Forum in Kazakhstan . Thus, having considered the various cultural foundations of volunteerism in four geographical regions, it can be noted that the culture of volunteerism in Central Asia is approaching China in terms of communitarianism. However, given globalisation, elements of American and European models of volunteerism are increasingly being integrated in Central Asian countries: individualism, pluralism, and social justice. --- Discussion The results of the study show that volunteer activity in Kyrgyzstan is undergoing development. Nevertheless, the survey results can be interpreted as positive, regarding the predominance of positive factors over negative ones. They show that volunteering in Kyrgyzstan is becoming a more modern and organised type of activity. This means that volunteering becomes a more effective tool for solving social problems and developing society. Motivational factors of volunteering show the predominance of rationality, while optimism prevails in prognostic images. Such trends point to the high potential of volunteering in Kyrgyzstan and the need to compare the features of volunteer motivation and experience in the framework of empirical data from other regions of the world. K. Petrovic et al. analysed a large volume of data from a sociological survey in Australia involving 8163 people. The main purpose of this study was to examine the relationship between religiosity and participation in volunteer activities. Preliminary data confirmed that attending religious services has a more significant impact on motivation for volunteering than subjective religiosity. The results partially confirmed this hypothesis. More frequent and active attendance at religious services correlated with an increased likelihood of participating in volunteer activities. On the other hand, more pronounced subjective religiosity was associated with more time spent on volunteer work. Researchers concluded that religious practices can increase the likelihood of participating in volunteer activities, but it remains unlikely if there are no subjective religious beliefs. These results have a number of similar aspects to the following study. Within its framework, a low religious component was recorded against the background of other factors . The main distinguishing feature of the Australian study is the attempt to analyse the religious aspect in more depth through the search for correlations between practices in combination with internal beliefs and the measured intensity of volunteer activity. The author's work focused on the Social & Legal Studios, Vol. 6,No. 4 general architectonics of motivational factors of volunteering, where religion was only one element among many others. Chinese researchers M. Guo et al. focused on the analysis of the relationship between Confucian values of charity and participation in volunteer activities. 473 Chinese students who filled out questionnaires were interviewed to assess Confucian values of charity, such as family, unity, and harmony. The results showed a positive relationship between Confucian values and participation in volunteer activities. However, no significant relationship was found between family life and volunteering. Moreover, the multigroup analysis showed that this correlation remained the same for students of both sexes in colleges. These results point to the important role of Confucian values of charity in stimulating volunteer activity among Chinese students, emphasising the influence of cultural factors on public participation and voluntary activity. The Chinese study had deeper and more concrete results in terms of the influence of a particular religious denomination on volunteer activity. In the author's research, within the framework of an open-ended question, there was also an emphasis on Islam, namely the "Sadaqah" principle, which is a structural component of this religious denomination. It was mentioned by the respondents themselves. Yet the main difference was the focus primarily on generalised religious motives without specifying Islam, which indicates a less in-depth analysis of the religious influence on volunteer behaviour. This comparison highlights the limitation of the author's work, which considered the religious component too generically. German researchers N. Moczek et al. focused on the motivation and personal characteristics of volunteers participating in the Insects of Saxony project. 116 volunteers took part in the sociological survey, most of whom were men, had higher education, were over 50 years old, and had been volunteering in biodiversity conservation projects for a long time. The volunteers showed prosocial and selfish motives for participating in the project, but they considered prosocial motives more important for their activity. The participants evaluated communication and feedback with the organisation as the most important aspects of volunteer activity. Participants also reported that their knowledge increased while participating in the project. While they were satisfied with the project as a whole, they were less satisfied with their own contribution. Nevertheless, most participants expressed a desire to continue their volunteer activities. These results highlight the importance of altruistic motives and attention to communication and feedback from volunteers for a successful volunteer programme in the field of biodiversity conservation. This German study confirms the results of the author's research, where altruism occupies a dominant place in the motivational structure of volunteer activity in Kyrgyzstan, and personal motives , such as professional career, emotional satisfaction occupies a secondary position. Yet it is necessary to indicate the main methodological difference. If in the author's study the sample was built according to the snowball method with the participation of volunteers from different projects, in this study, there was a small sample of volunteers from one specific project. S. Compion et al. analysed the motives of residents of Ghana, South Africa, and Tanzania to participate in episodic volunteering and determined whether these motives are similar to long-term volunteering based on membership or have differences. A survey of 1,000 participants was conducted in 2018. To analyse the data, logistic regression models were used to identify differences in motivations between beginners, casual, and permanent episodic volunteers. The survey results showed that age and student status affect the difference between novice volunteers and permanent volunteers. More importantly, novice volunteers are primarily motivated by social reasons, whereas regular volunteers are more focused on altruistic motives. This confirms that people can be motivated to volunteer for a variety of reasons that may coincide or complement each other, and these motives may vary depending on the stage of their lives. The study of African countries confirms the results of the author's research in terms of the fact that the motives for volunteering can have a different nature. This is confirmed by the fact that the answers to the question about the motives of volunteer activity had a greater statistical severity. Nevertheless, the social motive prevailed. The main difference of this study, conducted within the framework of African countries, is an attempt to conduct age differentiation of motivations. In other words, there a difference in motivation by age categories was recorded. It has been shown that with increasing age, altruistic motives begin to prevail more. Dutch researchers A.F. Faletehan et al. addressed the concept of "calling to work" in the context of nonprofit volunteering. This concept is commonly used to explain how people fulfil their vocation by doing meaningful work. Researchers suggest that it may be useful for understanding the motivation and retention of volunteers. The concept of "calling to work" in this context helps explain why people join non-profit organisations and stay there for a long time. The results lead to an important conclusion: volunteers can consciously choose to participate in meaningful activities and, thus, enjoy self-realisation and meaningfulness of life through volunteering. This approach helps to better understand the internal motivations of volunteers and explain why they leave their mark on non-profit organisations, which can be useful for developing strategies for retaining volunteers and increasing their level of satisfaction. This study examines the professional motives of volunteering in more detail. In the author's study, respondents were offered similar motives , but they were little statistically represented since socio-altruistic motives prevailed. The main difference between the study of Dutch scientists is a deeper understanding of the personal motives of volunteering not related to cultural or religious values. The focus is on satisfaction from activity, which is rather psychological in nature. M.S. Skinner et al. focused on the challenges faced by volunteers providing long-term care for the disabled. They analysed data from numerous sources to assess the degree of complexity of volunteering and informal care in this area. The results of the analysis showed that one of the common problems in cooperation between caregivers and volunteers is a lack of information and knowledge, and insufficient coordination of actions. These factors can create difficulties and cause difficulties in the organisation and provision of care, especially in the long term. This study highlights the importance of motivating volunteers and providing them with appropriate resources, training, and information to make volunteering more effective and sustainable, especially in the field of long-term care for the disabled. This study points to two important problems faced by volunteers -lack of awareness and lack of coordination in activities. As part of the author's research, similar problems faced by volunteers in Kyrgyzstan were also recorded. Coordination problems were the second most popular among volunteers, after problems with funding. At the same time, it is important that the lack of awareness of volunteers did not have a strong statistical representation, which indicates a lower priority of this problem in the Kyrgyz space. Thus, the research conducted over the past three years confirms that the motives of volunteering are complex and multifaceted. They may be related to religious, cultural, social and personal factors. In general, the following main motives of volunteer activity can be distinguished: altruismthe desire to help other people and make the world a better place; social ties -the need to communicate and interact with other people; personal development -the opportunity to acquire new skills and knowledge, develop as an individual. Depending on the cultural context, these motives may have different degrees of expression. In the author's study conducted in Kyrgyzstan, it was found that altruism is the most important motive for volunteering. This is because there is a strong tradition of mutual aid and charity in Kyrgyz culture. In addition to motives, the study also examines the problems faced by volunteers. The analysis of other studies mentioned: lack of coordination -there is often no coordination between volunteer organisations and official structures, which makes it difficult to work together; lack of awareness -volunteers often do not have complete information about the activities of volunteer organisations and how they can help. These studies expand the understanding of the motives and problems of volunteering. They show that volunteering is a complex and multifaceted activity that can have a positive impact on society. --- Conclusions The volunteers in Kyrgyzstan are clearly focused on supporting educational and cultural projects, which indicates their desire to contribute to the development and promotion of society in the field of education and culture. The orientation of volunteers to educational and cultural projects can play a key role in the formation of intellectual and cultural capital of society. This can contribute to improving the educational level of citizens and preserving cultural values. The volunteer activity in the country is increasingly based on rational motives, such as the desire to contribute to the improvement of society. There is a tendency towards professionalization and standardisation of volunteer activities, which can contribute to a more effective impact of volunteerism on social change and the development of society. The main challenge facing in Kyrgyzstan is the lack of funding and resources. This problem is caused by the fact that largely volunteer activity in the country depends on grants and donations. In the context of the current challenges that volunteers are facing in Kyrgyzstan, the most priority areas are social assistance, education and youth support, as well as health care, medical care and expansion of the legal and regulatory framework that would cover more issues related to volunteering. The areas that volunteers focus on in solving modern challenges reflect the key needs of Kyrgyz society. Most of the survey participants are optimistic about the future of volunteer activity in Kyrgyzstan. According to the respondents, the key areas for the development of volunteerism will be to increase funding and strengthen relationships with government agencies. Furthermore, respondents emphasise the importance of strengthening volunteer infrastructure and developing global cooperation. In general, the opinion of the survey participants reflects the belief in the potential of volunteering as a tool for solving social problems and improving the quality of life in Kyrgyzstan. The practical value of this study is focused on a wide range of potential actors who may be indirectly or directly related to volunteer activities. This study is a useful information resource for high-quality state policy in the field of volunteer activity. Further research should involve a detailed analysis of not only the temporal aspects of volunteering but also spatial aspects: the difference between volunteer activities in the regions of Kyrgyzstan and the features of volunteering in urban/rural environments. Анотація. Актуальність дослідження волонтерської діяльності в киргизькому суспільстві зумовлена гносеологічною потребою в комплексному осмисленні цієї сфери людської активності на сучасному етапі розвитку Киргизстану. Це відбувається з огляду на недостатню концептуалізацію цього питання в науковому просторі країни. У цьому дослідженні використано два основні теоретико-методологічні підходи: аксіологічний та праксеологічний. Для емпіричної частини дослідження було обрано метод опитування. Загальна кількість учасників дослідження склала 284 особи. Мета дослідження -проаналізувати мотивацію та особливості волонтерської діяльності в Киргизстані з огляду на історичні контексти, сучасні умови, законодавчу базу, та потенційні поля розвитку. Волонтери в Киргизстані активно підтримують освітні та культурні проекти, фокусуючись на розвитку суспільства в цих сферах. Соціальні проекти займають менш пріоритетну позицію. Основними мотивами для волонтерів є соціальна відповідальність та особисті інтереси, тоді як традиційні та релігійні чинники є менш значущими. Професіоналізація та стандартизація волонтерської діяльності стає все більш помітною, враховуючи раціональні мотиви. Основними викликами для волонтерів та волонтерських організацій в країні є брак фінансування та ресурсів, труднощі в організації проектів та обмежений доступ до професійної підготовки волонтерів. Пріоритетними сферами для волонтерської діяльності в сучасних умовах залишаються соціальна та юридична допомога, освіта, підтримка молоді, охорона здоров'я та медична допомога. Більшість респондентів висловили оптимізм щодо майбутнього волонтерської діяльності в Киргизстані. Вони впевнені, що вона буде продовжувати розвиватися і відігравати більш важливу роль у суспільстві. Покращення фінансування, посилення співпраці з державними органами, шляхом введення юридичної бази щодо діяльності волонтерів, розвиток даної інфраструктури та глобальна співпраця розглядаються як ключові фактори для ефективної організації волонтерської діяльності та вирішення соціальних та правових проблем у майбутньому. Дослідження містить цінну інформацію для державних інституцій, пов'язаних з волонтерською діяльністю, і буде корисним для розробки якісної державної політики у цій сфері Ключові слова: релігійні погляди; традиційні цінності; раціональність; глобалізація; альтруїзм; права волонтерів ---

The relevance of the study of volunteer activity in Kyrgyz society is due to the epistemological need for a comprehensive understanding of this sphere of human activity at the current stage of development of Kyrgyzstan. This is due to the insufficient conceptualisation of this issue in the country's scientific space. This study uses two main theoretical and methodological approaches: axiological and praxeological. The survey method was chosen for the empirical part of the study. The total number of participants in the study was 284. The purpose of the study is to analyse the motivation and features of volunteering in Kyrgyzstan, taking into account historical contexts, current conditions, legal framework, and potential areas of development. Volunteers in Kyrgyzstan actively support educational and cultural projects, focusing on the development of society in these areas. Social projects are less of a priority. The main motivations for volunteers are social responsibility and personal interests, while traditional and religious factors are less important. The professionalisation and standardisation of volunteering is becoming increasingly prominent, given the rational motivations. The main challenges for volunteers and volunteer organisations in the country are lack of funding and resources, difficulties in organising projects, and limited access to professional training for volunteers. Social and legal aid, education, youth support, healthcare and medical care remain priority areas for volunteering in the current environment. Most respondents expressed optimism about the future of volunteering in Kyrgyzstan. They are confident that it will continue to develop and play a more important role in society. Improved funding, stronger cooperation with government agencies by introducing a legal framework for volunteer activities, development of the infrastructure and global cooperation are seen as key

Figure 2 shows that as the UEE duration falls below human response times 26,27 , the number of both crash and spike UEEs increases very rapidly. The fact that the occurrence of spikes and crashes is similar suggests UEEs are unlikely to originate from any regulatory rule that is designed to control market movements in one direction, e.g. the uptick regulatory rule for crashes 16,17 . Their rapid subsecond speed and recovery shown in Figs. 1A and1B suggests they are also unlikely to be driven by exogenous news arrival. We have also checked that using 'volume time' instead of clock time, does not simplify or unify their dynamics. The extensive charts at www.nanex.net, of which Figs. 1A and1B are examples, show that the total volume traded within each UEE does not differ significantly from trading volumes during typical few-second market intervals, nor do the UEEs originate from one large but possibly mistaken trade. The horizontal green lines in Fig. 1C show that the UEEs started appearing at different times in the past for individual stock, but then escalated in the build-up to the 2008 global financial collapse . Moreover, these escalation periods tend to culminate around the 15 September bankruptcy filing of Lehman Brothers. Indeed, the ten stock with the most UEEs are all major banks with Morgan Stanley first, followed by Goldman Sachs . Figure 2 in the SI shows explicitly the escalation of UEEs in the case of Bank of America stock. For each stock shown in Fig. 1C, the start and end times of the escalation period are determined by examining the local trend in the arrival rate of the UEEs. In determining these start and end times, we checked various statistical methods such as LOWESS and found them all to give very similar escalation periods to those shown in Fig. 1C. We also find that the occurrence of UEEs is not simply related to the daily volatility, price or volume . Figure 1C therefore suggests that there may indeed be a degree of causality between propagating cascades of UEEs and subsequent global instability, despite the huge difference in their respective timescales. Although access to confidential trade and exchange information is needed to fully test this hypothesis, at the very least Fig. 1C demonstrates a coupling between extreme market behaviours below the human response time and slower global instabilities 2,5 above it, and shows how machine and human worlds can become entwined across timescales from milliseconds to months. We have also found that UEEs build up around smaller global instabilities such as the 5/6/10 Flash Crash: although fast on the daily scale, Flash Crashes are fundamentally different to UEEs in that Flash Crashes typically last many minutes and hence allow ample time for human involvement. Future work will explore the connection to existing studies such as Ref. 28 of market dynamics immediately before and after financial shocks. Having established that the number of UEEs increases dramatically as the timescale drops below one second, and hence drops below the human reaction time, we now seek to investigate how the character of the UEEs might also change as the timescale drops -and in particular, whether the distribution may become more or less akin to a power-law distribution. Power-law distributions are ubiquitous in real-world complex systems and are known to provide a reasonable description for the distribution of stock returns for a given time increment, from minutes up to weeks [13][14][15] . Our statistical procedure to test a power-law hypothesis for the distribution of UEE sizes, and hence obtain best-fit power-law parameter values, follows Clauset et al.'s 29 state-of-the-art methodology for obtaining best-fit parameters for power-law distributions, and for testing the powerlaw distribution hypothesis on a given dataset. Following this procedure, we obtain a best estimate of the power-law exponent a, and a p-value for the goodness-of-fit, for the distribution of UEE sizes. Specific details of the implementation, including a step-by-step recipe and documented programs in a variety of computer languages, are given in Ref. 29. Figure 3 shows a plot of the goodness-of-fit p-value, and the corresponding power-law exponent a, for the distribution of sizes of UEEs having durations above a particular threshold. As this duration threshold decreases, the character of the UEE size distribution exhibits a transition from a power-law above the limit of the human response time to a non-power-law below it --specifically, the goodness-of-fit p falls from near unity to below 0.1 within a small timescale range in Figs. 3B and3C. This loss of power-law character at subsecond timescales suggests that a lower limit needs to be placed on the validity of Mandelbrot's claim that price-changes exhibit approximate self-similarity across all timescales 30 . It can be seen that the transition for crashes is smoother than for spikes: this may be because many market participants are typically 'long' the market 16 and hence respond to damaging crashes differently from profitable spikes. Not only is the crash transition onset earlier in Fig. 3B than for spikes in Fig. 3C, it surprisingly is the same as the thinking time of a chess grandmaster, even though individual traders are not likely to be as attentive or quick as a chess grandmaster on a daily basis 26,27 . This may be a global online manifestation of the 'many eyes' principle from ecology 6 whereby larger groups of animals or fish may detect imminent danger more rapidly than individuals. Figures 4 and5 show further evidence for this transition in UEE size character as timescales drop below human response times. Figure 4 shows that the cumulative distribution of UEE sizes for the example of spikes, exhibits a qualitative difference between UEEs of duration greater than 1 second, where p 5 0.91 and hence there is strong support for a power-law distribution, and those less than 1 second where p , 0.05 and hence a power-law can be rejected. A similar conclusion holds for crashes. Figure 5 shows the cumulative distribution of sizes for UEEs in different duration windows, with the distribution for the duration window 1200-1500 ms showing a marked change from the trend at lower window values. The following quantities that we investigated, also confirm a change in UEE character in this same transition regime: a Kolmogorov-Smirnov two-sample test to check the similarity of the different UEE size distributions within different duration time-windows ; the standard deviation of the size of UEEs in a given window of duration ; the average and standard deviation in the number of price ticks making up the individual UEEs which lie in a given duration window ; a test for a lognormal distribution for UEE durations . Figure 9 of the SI confirms that using different binnings for the UEE durations does not change our main conclusions. --- Discussion Inspired by Farmer and Skouras' ecological perspective 6 , we analyze our findings in terms of a competitive population of adaptive trading agents. The model is summarized schematically in Fig. 1 of the SI while Refs. 31, 40 and 41 provide full details and derivations of the quoted results below. Each agent possesses several strategies, but only trades at a given timestep if it has a strategy that has performed sufficiently well in the recent past. The common information fed back to the agents at each timestep is a bit-string encoding the m most recent price movements [31][32][33][34][35] . The key quantity is g~2 mz1 =N corresponding to the ratio of the number of different strategies to the number of active agents N. For g . 1, there are more strategies than agents, which is consistent with having many human participants since individual humans have myriad ways of making decisions, including arbitrary guesswork, hunches and personal biases. Hence g . 1 is consistent with having many active human traders, which in turn is consistent with longer timescales since this is where humans can think and act. The g . 1 output, illustrated in Fig. 6B , does indeed reproduce many well-known features of longer timescale price increments 31 . The chance that many follows a power-law, for the subset having durations greater than 1 second and less than 1 second . For durations more than 1 second, there is strong evidence for a power-law . For durations less than 1 second, a power-law can be rejected. Black line shows best-fit power-law. agents simultaneously use the same strategy and submit the same buy or sell order, is small if g . 1, hence there are very few extreme price-changes --exactly as observed in our data for . 1 s. Reducing g below 1 corresponds to reducing the strategy pool size below the number of agents, which is consistent with a market dominated by specific high-frequency trading algorithms. As the trading timescale moves into the subsecond regime, the number of pieces of information that can be processed by a machine decreases since each piece of information requires a finite time for manipulation , which is consistent with a reduction in m and hence a decrease in g since g~2 mz1 =N. Remarkably, decreasing g continually in our model generates a visually abrupt transition in the output with frequent extreme pricechanges now appearing , which is exactly what we observed in the data for , 1 s. g , 1 implies more than one agent per strategy on average: crowds of agents frequently converge on the same strategy and hence simultaneously flood the market with the same type of order, thereby generating the frequent extreme price-change events. Although it is quite possible that there are other models that could reproduce a gradual change in the instability as g decreases, the task of reproducing a visually abrupt transition as observed empirically in Fig. 3 is far harder. In addition, our model predicts that the extreme event size-distribution in the ultrafast regime should not have a power law, exactly as we observe; that recoveries as in Figs. 1A and1B, can emerge endogenously in the regime g , 1 , again as we observe; and that extreme events can be diverted by momentarily increasing the strategy diversity. To achieve this latter effect, agents simply need to be added with complementary strategies --shown as complementary colors in the right panel of Fig. 6C --thereby partially cancelling the machine crowd denoted in red. The fact that the actual model price trajectory can then bypass the potential extreme event therefore offers hope of using small real-time interventions to mitigate systemic risk. Although the simplicity of our proposed minimal model necessarily ignores many market details, it allows us to derive explicit analytic formulae for the scale of the fluctuations in each phase, and hence an indication of the risk, if we make the simplifying assumption that the number of agents trading each timestep is approximately N . For g . 1, the scale is given by N 1 2 1{ 2 { mz1 ð Þ N À Á 1 2 for general s, while for g , 1 it abruptly adopts a new form with upper bound 3 { 1 2 2 { m 2 N 1{2 {2 mz1 ð Þ À Á 1 2 and lower bound 3 { 1 2 2 { mz1 ð Þ 2 N 1{2 {2 mz1 ð Þ À Á 1 2 for s 5 2. This predicted sudden increase in the fluctuation scale from being proportional to N 1 2 for g . 1, to proportional to N for g , 1, is consistent with the observed appearance of frequent UEEs at short timescales, and specifically the visually abrupt transition that we observe in Fig. 3. More detailed investigation of the properties of UEEs, and the potential implications for financial market instability, will require access to confidential exchange data that was not available in the present study. However a remarkable new study by Cliff and Cartlidge 36 provides some additional support for our findings. In controlled lab experiments, they found that when machines operate on similar timescales to humans 36 , the 'lab market' exhibited an efficient phase . By contrast, when the machines operated on a timescale faster than the human response time 36 then the market exhibited an inefficient phase . While our crowd model offers a plausible explanation of the observed transition in Fig. 3, we stress that our purpose in this paper was not to explain the details of the price changes during individual UEEs, nor was it to unravel the underlying market microstructure that might provoke or exacerbate such UEEs. A recent preprint by Golub et al. 37 claims that a majority of all UEEs carry the label of ISO . However this claim does not affect the validity of our findings. Moreover, Ref. 37 does not uncover or explain the visually abrupt transition that we observe in Fig. 3, nor does it invalidate our own crowd model explanation. Irrespective of the underlying order identities, every UEE is the result of a sudden excess buy or sell demand in the market, and our model provides a simple explanation for how sudden excess buy or sell demands are generated, not how they get fulfilled. Indeed it is a common feature of our model output that a large imbalance of buy or sell demand can suddenly appear, producing a UEE as observed empirically. We also note that Golub et al. 37 make several strong assumptions in their attempts to label the UEEs, each of which requires more detailed investigation since the resulting identifications are neither unique nor unequivocal. Whether the visually abrupt transition in Fig. 3 is a strict phase transition in the statistical physics sense, also does not affect the validity of our results. The extent to which UEEs were provoked by regulatory and institutional changes around 2006, is a fascinating question whose answer depends on a deeper understanding of the market microstructure along the lines started by Golub et al. 37 . It may be that ISOs are particularly problematic, but this is still unclear because of the assumptions made in Ref. 37. Once this has been resolved, it should be possible to make definite policy recommendations based on our findings, as well as expanding the study to connect to systemic risk 38 and derivative operations 39 . --- Methods The power-law analysis that we use to obtain our main result in Fig. 3, follows the state-of-the-art testing procedure laid out by Clauset et al. 29 . Our accompanying crowd model considers a simple yet archetypal model of a complex system based on a population of agents competing for a limited resource with bounded rationality. This model has previously been shown to reproduce the main stylized facts of financial markets 31 . Its dynamics are based on the realistic notion that it is better to be a buyer when there is an excess of sellers or vice versa when in a financial market comprising agents with short-term, high-frequency trading goals. The formulae given above for the scale of the fluctuations in each phase, are derived explicitly in Ref. 40, and also Refs. 31 and 41. views and conclusions contained in this paper are those of the authors and should not be interpreted as representing the official policies, either expressed or implied, of the above named organizations, to include the U.S. government. We thank Amith Ravindar, Joel Malerba, Zhenyuan Zhao, Pak Ming Hui, Spencer Carran, David Smith, Michael Hart and Paul Jefferies for discussions surrounding this topic and help with assembling datafiles and parts of figures. --- --- Additional information

Society's techno-social systems are becoming ever faster and more computer-orientated. However, far from simply generating faster versions of existing behaviour, we show that this speed-up can generate a new behavioural regime as humans lose the ability to intervene in real time. Analyzing millisecond-scale data for the world's largest and most powerful techno-social system, the global financial market, we uncover an abrupt transition to a new all-machine phase characterized by large numbers of subsecond extreme events. The proliferation of these subsecond events shows an intriguing correlation with the onset of the system-wide financial collapse in 2008. Our findings are consistent with an emerging ecology of competitive machines featuring 'crowds' of predatory algorithms, and highlight the need for a new scientific theory of subsecond financial phenomena.s discussed recently by Vespignani 1 , humans and computers currently cohabit many modern social environments, including financial markets 1-25 . However, the strategic advantage to a financial company of having a faster system than its competitors is driving a billion-dollar technological arms race [6][7][8][9][16][17][18][19] to reduce communication and computational operating times down to several orders of magnitude below human response times 26,27 --toward the physical limits of the speed of light. For example, a new dedicated transatlantic cable 18 is being built just to shave 5 milliseconds (5 ms) off transatlantic communication times between US and UK traders, while a new purpose-built chip iX-eCute is being launched which prepares trades in 740 nanoseconds 19 (1 nanosecond is 10 29 seconds). In stark contrast, for many areas of human activity, the quickest that someone can notice potential danger and physically react, is approximately 1 second 26,27 (1 s). Even a chess grandmaster requires approximately 650 ms just to realize that she is in trouble 26,27 (i.e. her king is in checkmate). In this paper we carry out a study of ultrafast extreme events (UEEs) in financial market stock prices. Our study is inspired by the seminal works of Farmer, Preis, Stanley, Easley and Cliff and co-workers 2,3,6-9 who stressed the need to understand ultrafast market dynamics. To carry out this research, we assembled a high-throughput millisecond-resolution price stream across multiple stocks and exchanges using the NANEX NxCore software package. We uncovered an explosion of UEEs starting in 2006, just after new legislation came into force that made high frequency trading more attractive 2 . Specifically, our resulting dataset comprises 18,520 UEEs (January 3rd 2006 to February 3rd 2011) which are also shown visually on the NANEX website at www.nanex.net. These UEEs are of interest from the basic research perspective of understanding instabilities in complex systems, as well as from the practical perspective of monitoring and regulating global markets populated by high frequency trading algorithms.We find 18,520 crashes and spikes with durations less than 1500 ms in our dataset, with examples of each given in Fig. 1A (crash) and 1B (spike). We define a crash (or spike) as an occurrence of the stock price ticking down (or up) at least ten times before ticking up (or down) and the price change exceeding 0.8% of the initial price, i.e. a fractional change of 0.008. We have checked that our main conclusions are robust to variations of these definitions. In order to have a standardized measure of the size of a UEE across stocks, we take the UEE size to be the fractional change between the price at the start of the UEE, and the price at the last tick in the sequence of price jumps in a given direction. Since both crashes and spikes are typically more than 30 standard deviations larger than the average price movement either side of an event (see Figs. 1A and1B), they are unlikely to have arisen by chance since, in that case, their expected number would be essentially zero whereas we observe 18,520.

INTRODUCTION Film is still the favorite as a medium for conveying messages in mass communication studies. In a broad sense, film can be interpreted as presenting images on the big screen and broadcast on TV. Film media is one of the electronic media in the form of audio visual as a cultural forum . Film trends are now converging with television. For example, in the United States there is the film King Kong which was converged into a television series . The film Horror-Ngeri Sedap is a family comedy genre film that tells the story of Batak culture. This film was directed by Bene Dion and released on June 2 2022. This 114 minute film was liked by 96% of the audience. Cultural richness that highlights Toba Batak culture. The filming process for this film was carried out around Lake Toba, North Sumatra Province while showing the beauty of Holbung Hill. The definition of film according to Law no. 8 of 1992 concerning film is a creative work of art and culture which is one of the audio-visual mass media created based on the principles of cinematography recorded on celluliod tape, video tape, video plates and the results of technological inventions in all forms and sizes . The film "Ngeri-NgeriSedap " is interesting to research because apart from highlighting the customs and culture of the Batak tribe, this film also conveys moral messages about the position of an overseas child who has to go home when his parents ask him to return to his hometown. This film depicts real life in the life of the Batak tribe in North Sumatra. This film stars ArswendyBeningSwara as Pak Domu, TikaPanggabean as Marlina/MakDomu, Boris Bokir as Domu , GhitaBhebhitaSarma , Lolok as Gabe , Rita Matu Mona as OppungDomu , Paulus Simangunsong as AmangAnggiat, Indah Permata Sari as Neny, Pritt Timotius as Pak Pomo, FitriaSechan as Mrs. Neny, Oppung Samantha as MamakMarlina. This film will start airing on Netflix on October 6 2022. One of the factors that influences the occurrence of conflict and problems in the family is a lack of awareness of good communication. Many families do not understand the importance of effective communication within the family, so that misunderstandings or disagreements often occur on various matters. This research was conducted to explore ethics as a family communication message in the Toba Batak community. In addition, this research is to look at the potential for family training and assistance to be provided with the aim of increasing family communication awareness and helping families develop effective communication skills. The formulation of this research problem is important to see how the horror film deliciously conveys the message of family communication awareness in the Toba Batak community. With this program, it is hoped that families in the Toba Batak community can better understand the importance of good communication in the family and can develop effective communication skills. so that you can build a harmonious and happy family. Semiotic studies are one method that can be used to analyze the use of symbols and metaphors in films. It is hoped that this research can contribute to the development of family training and mentoring programs in the Toba Batak community as well as to the development of knowledge about the importance of communication awareness in the family. --- Definition of Family Family is a kinship relationship or household that is related by blood as a result of marriage. The family is also a social group that has the characteristics of living together, there is economic cooperation by carrying out family functions such as giving birth and caring for children, resolving problems, and caring for each other among family members. --- Family Communication Understanding Family Communication Communication is the most important aspect, this is related to all aspects of a couple's relationship. The process of making decisions that originate from discussions within the family. Both in terms of finances, children, career, religion, and style, patterns and skills in communication. The process of exchanging information, messages and meaning between family members to build good relationships, fulfill communication needs, and maintain family balance and stability is the definition of family communication. According to Kathleen Galvin and Bylund family communication is: the process of interaction, verbal and nonverbal between family members in creating meaning and maintaining family relationships." Meanwhile, Fitzpatrick and Mottet define family communication as "the process of conveying information, values, beliefs and feelings between family members, which includes verbal and nonverbal communication." It can be concluded from the definition above that family communication is a process of exchanging information, messages and meaning between family members with the aim of building good relationships and maintaining family balance and harmony. --- Family Communication Function Several functions of family communication that can be described as follows are 1). Establishing closeness and attachment between family members , 2). Building family identity and strengthening relationships between family members 3). Organize and divide family tasks effectively , 4). Establishing healthy relationships between family members, 5 ). Providing emotional and psychological support between family members, 6 ). Building trust between family members, 7 ). Resolving conflicts or problems in the family in a positive and effective way, 8 ). Improving the social skills of family members, especially children who are still in the developmental stage, 9 ). Preparing family members to interact with society and the environment outside the family, 10 ). Maintain and improve the overall welfare of the family. --- Types of Family Communication According to Fitzpatrick and Vangelisti The Toba Batak people are one of the ethnic groups in Indonesia who live in the Tapanuli area, North Sumatra. According to several experts, the history and background of the Toba Batak people, according to the origins of the Toba Batak people, is believed to come from the Proto Malay tribe, which originally settled in Southeast Asia and moved to the archipelago. Several archaeological studies show that the Toba Batak have lived in the area since the Neolithic era, around 4000 years BC. The Toba Batak people have very strong beliefs and customs, one of which is the Batak religion called Parmalim. This belief is believed to have existed since the time of the Toba Batak kingdom in the 14th century. Apart from that, the Toba Batak people also have various customs, such as traditional ceremonies, household arrangements, and relationships between family and community. Initially they were farmers, but as time progressed, this community also developed the plantation and livestock sectors. In the 19th century, Dutch colonial influence also had an impact on the economic development of the Toba Batak people. In the past, it was divided into several small kingdoms, such as the Sisingamangaraja, Silindung and Samosir kingdoms. However, in the 19th century, Dutch colonial influence resulted in the division of territories and these kingdoms being abolished. After Indonesia's independence, the Toba Batak people were also active in political struggles and became part of the formation of the Indonesian state. According to Silalahi , Toba Batak culture is one of the cultures in Indonesia, specifically in North Sumatra. The Toba Batak people have rich customs and traditions, such as traditional ceremonies, dances, carvings and music. They also have a strong kinship system and tend to be patrilineal, where the lineage is counted from the father's side. The Toba Batak people also have the habit of maintaining huta, which is a natural environment that is considered the center of their life and culture. In the past, the Toba Batak people were known as farmers and hunters, but over time, most of them changed professions to become traders and entrepreneurs. --- Semiotic Theory First, this framework requires an understanding of semiotic theory. Semiotics is the study of signs or symbols and how these signs are used to convey meaning. In this research, semiotics is used to understand how symbols and metaphors in films are used to create meaning. Wibisono, P., & Sari, Y. , Use of Symbols and Metaphors in Film. Second, this framework will explore the use of symbols and metaphors in films in general. The use of symbols and metaphors in films can help create stronger and more effective messages to convey to the audience. This research will identify the symbols and metaphors used in the film Ngeri-Ngeri Sedap. Audience Awareness in Film. Third, this framework will explore how audience awareness is built through symbols and metaphors in films. In this case, audience awareness refers to the audience's understanding of the message the film wants to convey. Links to Social Context. Fourth, this framework will explore the relationship between the use of symbols and metaphors in the film Ngeri-Ngeri Sedap and the Indonesian social context. Films are often used as a medium to convey social and cultural messages. This research identifies how the symbols and metaphors in the film Ngeri-Ngeri Sedap are related to the Indonesian social context and how social messages are conveyed through symbols and metaphors in semiotic studies This film tells the story of two Batak parents who pretend to fight to get their child to come home from their overseas city. There is only one child living with them, namely Sarma, who is the second child of the couple Pak Domu and Mak Domu. Meanwhile, his three other children migrated to the capital. Film is one of the most popular art forms in the world. As a complex medium, film utilizes various elements and techniques to convey messages and touch the hearts of the audience. One technique that is often used in films is symbols and metaphors. Symbols and metaphors are used in films to convey complex messages or ideas briefly and concisely. The family is an important institution in society. A harmonious and happy family will have a positive impact on its members and society as a whole. However, conflicts and problems often occur in families, including in the Toba Batak community, which can threaten family integrity and harmony. This film will take several examples of situations in everyday life where poor communication can cause problems in the family. Examples of this may include situations such as disagreements in choosing a child's education, differences in views in choosing a job, or family financial problems. --- RESEARCH METHODS This study used qualitative research methods. Qualitative research is a type of research that aims to understand meaning, actions and social interactions from the perspective of research subjects or participants. Qualitative research is suitable for exploring complex topics and specific contexts such as awareness of family communication among the Toba Batak community. In qualitative research, data is collected through in-depth interviews, observation, and document analysis, and analyzed using qualitative analysis techniques such as thematic analysis or grounded theory. Data collection was carried out using a literature review. Data was collected from various sources related to relevant theories and concepts. With this framework, it is hoped that this research can provide a deeper understanding of how the use of symbols and metaphors in films can be used to create awareness in the audience and provide an overview of how films can be used as a medium to convey social messages and create awareness in society. . The theoretical framework that can be used as a basis for the study of the semiotics of the film Ngeri-NgeriSedap is the semiotic theory by Ferdinand de Saussure: Saussure divided signs into three categories, namely syntagm, paradigm, and syntagm-paradigm. Syntagms are signs that are connected sequentially and form sentences. Paradigms are signs that are related horizontally and form categories. Syntagm-paradigm are signs that are related vertically and form a structure. Mise-en-scène is a visual component consisting of layout, lighting and decoration. Cinematography is a way of filling films with moving images. Sound is the way sound is used in a film. Editing is the way film scenes are cut and arranged. --- RESULTS AND DISCUSSION In this modern era, film has become a very popular communication medium in society. The importance of communication in the family has been the focus of research in various fields, including psychology, sociology, and family science. However, there are still many families who do not understand the importance of good communication within the family, including in the Toba Batak community. According to Situmorang , there are still many families in the Toba Batak community who experience conflicts and problems within the family due to a lack of awareness of good communication. This can have a negative impact on family unity and happiness. Efforts to increase awareness of family communication in the Toba Batak community, training and family mentoring programs can be an effective solution. According to Setiawan, D. , family training and mentoring programs have proven effective in increasing family communication awareness and helping families develop effective communication skills. Family training and assistance programs also have several factors that influence their success. According to Uhl-Bien and Marion , factors such as companion expertise, social support, and the family's willingness to participate in the program can influence the success of family training and assistance programs. In the context of the Toba Batak community, several previous studies have studied communication within the family and its influence on family harmony. According to Lubis , there are several factors that influence Toba Batak family harmony, including poor communication within the family. Therefore, it is hoped that this research can make a positive contribution to the development of family training and mentoring programs in the Toba Batak community and increase knowledge about the importance of communication awareness in the family. A study of the semiotics of the film Ngeri-NgeriSedap will provide an important contribution to understanding how this film functions as a communication medium that can convey messages and communicate meaning to the audience. This study will also help to reveal the characters and themes contained in the film Ngeri-NgeriSedap. Several previous studies have examined the use of symbols and metaphors in films as a way to create meaning and messages for the audience. For example, Menyuk conducted a study that examined the use of symbols in Hollywood films and showed how symbols can be used to convey complex ideas, such as love, death, or freedom. Meanwhile, Jørgensen examines the use of metaphor in films and shows how metaphors can be used to express the values and ideology underlying a film. Another study conducted by Anderson shows that symbols and metaphors can be used to create meaning in films and help audiences understand the message the director wants to convey. In the Indonesian context, several studies have shown that films can be used as a medium to convey social messages to society. For example, research by Sya'dian, T. , shows how Indonesian films are used to convey messages about social, political and cultural life in Indonesian society. However, there is a lack of research on the use of symbols and metaphors in Indonesian films, especially in the context of creating awareness in the audience. Therefore, this research aims to explore how symbols and metaphors in the film Ngeri-NgeriSedap can be used to create awareness in the audience, as well as provide new insights into how films can be used as a medium to convey social messages to society. Therefore, it is necessary to conduct a study that explores the symbolic meaning behind the tension and frightening power contained in the film Ngeri-NgeriSedap through semiotic analysis. "Thus, this study will make an important contribution to understanding how the film Ngeri-NgeriSedap can function as a communication medium that can influence the thoughts and behavior of the audience." Semiotics or sign theory is a science that studies signs and their meaning in a system. This concept was first introduced by Ferdinand de Saussure at the beginning of the 20th century. In general, semiotics is the science that studies how humans create, use and understand signs. According to Charles Sanders Peirce, an American philosopher who is also considered the father of semiotics, a sign is anything that refers to an object or other thing. Signs can be words, images, sounds, gestures and actions. Semiotics studies how signs are interpreted and provide meaning to the world around us. On the other hand, Roland Barthes, a French literary expert and cultural critic, defined semiotics as a critical method for studying sign systems and how these signs interact with humans. He argued that language and signs are not something natural, but are shaped by culture and society. Meanwhile, Umberto Eco, an Italian semiotician and writer, stated that semiotics not only studies verbal signs or language, but also non-verbal signs such as colors, shapes and symbols. He developed the concept of "interpretation" in semiotics, where each individual has different experiences and knowledge, so they can give different meanings to the same sign. Overall, semiotics is an interdisciplinary science that studies signs and their meanings in various contexts, both cultural, social and individual. The concept of semiotics can be used to understand and analyze various phenomena in the world, such as art, literature, media and popular culture. Concept: This film will discuss the importance of awareness of family communication among the Toba Batak community. The film will show several examples of situations in everyday life where poor communication between family members can lead to conflicts and problems within the family. The aim of this film is to increase awareness of the Toba Batak people about the importance of good and effective communication within the family. It is hoped that this film can help improve relationships between family members and improve the overall quality of family life. In each example situation, the film will show how effective communication between family members can help solve problems and avoid conflict. The film will also highlight the importance of listening to each other and speaking honestly and openly within the family. The film will also show how poor communication can affect the emotional and mental health of family members. In some instances, films can show how the inability to communicate effectively can lead to emotional distress and even anxiety or depression. This research discusses awareness of family communication among the Toba Batak community. The research results show that poor communication between family members can cause conflict and problems within the family. In several examples of situations in everyday life, it was found that effective communication between family members can help solve problems and avoid conflict. This research is of interest in promoting awareness of the importance of good communication within the family. The Toba Batak people, as research subjects, have a strong culture of valuing family and togetherness, but in some cases, poor communication can disrupt family relationships and cause conflict. awareness of family communication among the Toba Batak community, this film can be an effective medium for conveying messages about the importance of good communication in the family to the Toba Batak community. By using visual techniques such as animation or dramatic reconstruction, this film can show examples of situations in everyday life where poor communication can cause conflict and problems within the family. It is hoped that this film will increase the awareness of the Toba Batak people about the importance of good communication within the family, as well as help improve relationships between family members and improve the quality of family life as a whole. The research results show that awareness of family communication among the Toba Batak community still needs to be improved. In several examples of situations in everyday life, it is found that poor communication between family members can cause conflicts and problems within the family. Situations found in research include disagreements in choosing a child's education, differences in views in choosing a job, or family financial problems. In each example situation, it was found that effective communication between family members can help solve problems and avoid conflict. However, when communication is ineffective, it can lead to emotional distress and even anxiety or depression. This research, it was found that it is important to listen to each other and talk honestly and openly in the family. This can help increase awareness of family communication among the Toba Batak community and help improve relationships between family members and improve the overall quality of family life. --- CONCLUSION Based on the research results, it can be concluded that awareness of family communication among the Toba Batak community is still important. Poor communication between family members can cause conflict and problems within the family. In several examples of situations in everyday life, it was found that effective communication between family members can help solve problems and avoid conflict. The importance of listening to each other and speaking honestly and openly within the family can help increase awareness of family communication among the Toba Batak community. This film will highlight the importance of awareness of family communication among the Toba Batak community. It is hoped that this film can help increase public awareness of the importance of good and effective communication in the family, as well as help improve relationships between family members and improve the overall quality of family life. From the perspective of semiotic studies , the film Ngeri-NgeriSedap combines elements of the Peirce and Barthes models, namely Batak cultural discourse becomes a cultural symbol and gives birth to new denotative meanings . Suggestions, based on the research results, there are several suggestions that can be given as follows: 1. Education. Better education about the importance of good communication within the family can help increase awareness of family communication among the Toba Batak community. Targeted and structured educational programs can be designed to increase awareness and communication skills among families. 2. Development of intervention programs. Intervention programs aimed at helping families overcome conflicts and problems caused by poor communication can be developed. These programs may include family communication skills training and family counseling to help improve relationships between family members. --- Communication media The film Ngeri-NgeriSedap: Awareness of Family Communication among the Toba Batak Community can be used as a medium to increase awareness of the Toba Batak community regarding the importance of good communication within the family. The right communication media like this can help convey messages in a more effective way and can reach more people.

This film provides insight into the importance of effective communication in the family. This film also depicts the richness and complexity of Toba Batak culture. How these cultural symbols can be analyzed from a semiotic perspective. The formulation of this research problem is important to see how the horror film deliciously conveys the message of awareness of family communication in the Batak Toba community using semiotic analysis. Based on the conflict between a Batak family and their four children who migrated to the capital. The method used is a qualitative method with a cultural semiotic approach. The Toba Batak tribe adheres to very strict customs. This film is able to bring awareness to this through the conflicts and solutions presented in the story of this film. The results of the research are that language becomes messages and symbolic meanings that can be an inspiration for the public to increase awareness of communication within the family and help create a harmonious and happy family.

INTRODUCTION A recent position paper asserted that enthusiasm for patient and public involvement in research has never been higher . PPI refers to incorporating the individual expertise of service users with lived experience and/or the collective perspectives of 'ordinary' citizens in research-related activities and structures . PPI is considered the key feature of participatory research . Participatory research covers a great variety of interrelated research approaches , such as participatory evaluation, collaborative research and participatory action research . The popularity of PPI in research, which is also reflected by the requirements of research funders , coincides with the growing attention for PPI in the broader social context . The anticipated gains of PPI include the relevance of the research, its efficiency and its effectiveness . While PPI is also becoming more common in health promotion research , the evidence for the added value of PPI in research has been mostly summarized by review studies in other health domains. For example, PPI in health and social care research made service users feel empowered, valued and more skillful, while researchers gained a greater understanding of their research area and communities became more knowledgeable about their condition . Another example is that PPI in health and health care research improved patient information, patient involvement in decision making and quality of care . It also increased study enrollment rates and aided researchers in securing funding, designing their studies and choosing relevant outcomes . Despite these added values, reviews typically observed that evaluation studies of PPI in research usually poorly theorized the concept being studied . The included studies rarely provided an explicit definition of PPI . Also, the studies typically lacked clear study objectives with respect to PPI , started from policy frameworks rather than from models for PPI , and provided little detail about the process of the public involvement itself . Findings like these made the position paper conclude that a 'striking lack of clarity' remains about what PPI in research actually entails . Central to its conceptualization are the underlying reasons-or rationales-for which PPI in research is set up . We are aware of just one publication that touched upon such rationales for PPI in health promotion research . In their review, the authors recognized two 'streams' of participatory evaluation . The first was practical participatory evaluation . Its underlying assumption-or rationale-is that PPI in research supports program, policy and organizational decision making by enhancing the relevance, ownership and thus utilization of the evaluation findings . The second stream was transformative participatory evaluation . Here, the underlying reason-or rationale-for PPI in research includes seeking to achieve social change by empowering members of community groups who are less powerful than, or are otherwise oppressed by, dominant groups . Despite the recognition of these two 'streams', the authors of the review concluded that, in health promotion research too, PPI has been prompted by situational and contextual factors rather than by theoretical definitions and distinctions . The lack of theoretical underpinning of PPI in research is problematic for two reasons. First, its hampers the implementation of PPI in research practice. While different rationales tend to be present-albeit mostly implicitly-in one and the same situation , dissimilar rationales are likely to become incompatible once they become manifest . That is, the different reasons underlying PPI may have conflicting implications for the design of the participatory process, which includes dimensions like who to engage, i.e. which patients and/or public to involve, what to engage them in, in what way, and when . In other words, '[I]n many cases, recommendations about how the involvement should be undertaken cannot coherently be formulated without some sense of why it should be undertaken' . The lack of clarity about what PPI entails may thus explain why it is frequently reported that expectations are not met and that an overarching concern remains about tokenistic involvement . Second, due to its poor conceptualization, evaluations of PPI in research have remained descriptive rather than evaluative , so that the evidence base for its added value can be characterized as anecdotal, partial, weak and lacking coherence . This in turn also precludes further theory building , for instance regarding the internal coherence of the concept of PPI , including how the different rationales for PPI link up with the various dimensions of the participatory process . Hence, it is necessary to reflect on and build an understanding of what PPI in research looks like in relation to the reasons for setting it up . As we are not aware of any publication about the different underlying reasons for PPI in health promotion research, in this article, we provide a conceptual overview of rationales for PPI, with the ultimate aim of better understanding, guiding and interpreting PPI in health promotion research. In order to demonstrate the presence of different rationales for PPI in real-world research, as well as to support the interpretation of our review findings and to facilitate the identification and application of rationales, we will illustrate each of the presented rationales with a practical example from a case study on patient involvement in a research program on Lyme disease in the Netherlands. --- METHODS --- Critical review We used a critical review methodology, as such a methodology aims to identify relevant publications, is appropriate for arriving at a synthesis of existing schools of thought, and-instead of starting from a hypothesis-typically results in a conceptual model . Here, the model consists of conceptually distinct categories of rationales for PPI in health promotion research. Our critical review followed the Search, Appraisal, Synthesis and Analysis framework . --- Search With our search, we aimed to gain as complete as possible a picture of prevailing rationales for PPI. Therefore, we searched for reasons underlying PPI in research, policy and practice, in both the health promotion domain and other domains. First, we examined the literature compiled during our previous work on PPI in health promotion . Second, we searched PubMed and PsycINFO for publications with the following terms, as well as related terms, in the title and/or the abstract: 'motives', 'reasons' or 'rationales'; and 'involvement', 'engagement' or 'participation'; and 'health', 'health promotion' or 'research'. We did not limit the publication date, as publications explicitly reporting on rationales appeared to be scarce. Third, we scanned papers thought to be relevant for the actual presence of rationales for PPI. Fourth, we applied extensive snowballing and forward citation searching to papers including such rationales. The search strategy was first carried out in 2015, and extensively updated in 2021. Finally, JH selected 47 publications for further appraisal. --- Appraisal As is common for this type of review , we did not undertake a formal quality assessment. Instead, JH and KK examined and discussed each publication for its conceptual contribution. Documents that, according to both JH and KK, included a theorydriven or empirically derived typology of rationales for PPI were selected for further synthesis . Excluded were publications that merely referred to or duplicated previously described typologies of rationales, focused on dimensions or determinants for involvement, lacked a sufficiently detailed description or did not make a conceptual contribution . --- Synthesis A critical review, such as ours, usually uses a narrative synthesis . From the 28 included papers, JH extracted the following information: authors, year and type of publication, and domain and type of participants; the original names given to the rationales and a summary of all the rationales for PPI described. This resulted in 23 typologies of rationales for PPI : in research in the health domain , in research in a domain other than health , in policy or practice in the health domain , and in policy or practice in a domain other than health . A comparison of the typologies by JH and KK revealed that authors differed in the number of rationales they distinguished, as well as that different names could be used for rationales with a similar content, and that similar names could be attached to rationales with a different content. Therefore, in order to arrive at conceptually distinct categories of rationales for PPI, we chose to base our narrative synthesis on a content-driven analysis . --- Analysis From the summaries of rationales, JH and KK defined distinct categories of rationales based on the characteristics that were regarded as most discriminative, i.e. those that were most likely to typify one category, but least likely to typify any of the other categories. Names for each of the categories were derived from the original publications by choosing the corresponding name that was regarded as the most descriptive. The resulting five conceptually different categories of rationales were reviewed and agreed upon by all authors. --- Illustrations --- Participatory case Practical examples to illustrate the rationales for PPI were selected from a case study on patient involvement in research on Lyme disease . This qualitative study was inspired by the findings of the literature search we conducted in 2015. The participation of patients was organized as part of a special Lyme research program by the Netherlands Organization for Health research and Development . The research program, worth 1 million euros, was commissioned by the Dutch Minister of Health, Welfare and Sports in response to a debate in the Lower House of the Dutch parliament about a citizens' initiative's petition asking for more research on Lyme disease. A ministerial requirement for the program was the involvement of the two Dutch patient associations for Lyme disease. The call for research proposals stated that: 'The emphasis lies on research that meets the questions that address the knowledge gap experienced by Lyme patients in order to build a bridge between patients, practitioners and scientists' . This bridge was thought to be needed to solve the heated dispute between patients and researchers about the case definition of Lyme disease. Patients with chronic symptoms in particular strongly disagreed with the latest guidelines , as the approved diagnostic tests would mean that chronic patients like them did not have the disease. A simultaneous aim of the research program was to set the national agenda for Lyme research . The involvement of patients included taking part in two invitational conferences to decide on the research agenda for the Lyme program; assessing the initial proposals for research ; taking part in the design of the full study proposals; assessing the full research proposals ; staying connected to the studies-for which the grants had been awarded-while they were being conducted; and playing a part in the interpretation of the research findings in the scientific reports. --- Interviews To learn how the patient involvement took shape, we asked the 12 persons who had a key role in the participatory process to share their experiences. LR conducted 10 semi-structured interviews with representatives of the patients' associations , the principal researchers of the studies , staff members of the funder , the trainer who supported the patients , and members of the assessment committee of the research program . Perceptions discussed included the underlying reasons for participation , the design of the participatory approach , the course of the participatory process, and the type of results that the participation was yielding. The interviews were transcribed verbatim. The transcripts were analyzed for manifestations of the different rationales for PPI by JH, KK and LR. The findings from this analysis induced us to update our literature review in 2021. The qualitative analysis was mostly deductive, as we aimed to identify the theoretical concepts, i.e. the rationales for PPI, in the interview data. Examples to illustrate the different rationales were discussed by JH and KK until consensus was reached. --- Ethical considerations According to the Dutch Medical Research Involving Human Subjects Act, this study did not require approval by a medical research ethics committee. All 12 respondents gave verbal consent for the use of the interview data for research purposes. Two of them additionally wanted to read and give permission for the publication of quotations from their interview. Quotations of seven different respondents were used to illustrate the presence of the different rationales in the Lyme research case. To warrant their anonymity, the respondents are referred to only by their role in the research program, e.g. representative of patient association, researcher or funder. --- RESULTS --- Categories of rationales The five categories of rationales we distinguished were democratic , consumerist , transformative , substantive and instrumental . The democratic rationale is in essence deontological , while the substantive and instrumental rationales are of consequentialist origins . The consumerist and transformative rationales both include deontological and consequentialist elements. --- Democratic In general, the democratic rationale highlights the normative right of citizens to democratic decision making . A participatory process is seen as self-evidently good, without reference to the ends in question . All interested or affected citizens should be represented in the assessment and selection of alternatives ). Democratic decision making additionally reflects the desirability of equity of access, empowerment of process and equality of outcomes for all citizens ). Although in principle an end in itself, democracy is also described as a means to protect citizens from decisions going against their interests and to counter the prevailing powers . In the context of research, the democratic rationale refers to the right of citizens to have a voice in research that may affect them . This implies that PPI in research is the right thing to do and is of intrinsic value . Citizens should have a voice in the formulating, conducting and implementing of research . Through the representation of their values and preferences, PPI contributes to transparent, accountable and responsible research . In research too, democracy is described as a means to an end: it could equalize power imbalances between the public and the academic community . The presence of the democratic rationale in the Lyme research case is illustrated in Box 1, suggesting that the issue of representation might be important in the 'who' dimension. --- Consumerist Consumerist justifications for citizen involvement relate to neo-liberal and economic rights , such as the right to individual choices in the marketplace and the rights of individual taxpayers or consumers in health care . Consumer involvement is an essential component of markets : it strengthens the public's voice in decisions about the organization and delivery of health services . As a means to an end, it may also promote patient-focused care , by incorporating patients' personal preferences and decision making in health care . Consumers or customers may demand services to be the way they want them, which in turn may also influence service outcomes . Involvement is then a lever to enhance the responsiveness of service providers and to redress power inequalities between health professionals and patients . In research, the consumerist rationale includes valuefor-money justifications similar to those explained above. It particularly concerns the rights of stakeholders with-individual, organizational or political-interests , such as lobby groups , to have a say in and demand what they consider the best research. Involvement may then serve as a tool for both scientists and societal groups to advocate their perceptions and values , so as to ensure that the studies conducted and/or the knowledge produced will support-or at least not conflict with-their interests. The presence of the consumerist rationale in the Lyme research case is illustrated in Box 2, indicating that patients and researchers might represent opposing stakeholder groups. --- Transformative In general, the transformative rationale is rooted in the normative concept of social justice . Core to this rationale is the amelioration of social inequities . Providing oppressed and marginalized groups with opportunities to have a voice allows them to gain control over the decisions that affect their lives . Such transformation links up to the notion of empowerment , which may serve both as a means and an end . Empowerment encompasses awareness raising, social learning and capacity building . For individuals, empowerment may strengthen competencies, responsibility and political consciousness and engagement Box 1: Illustration of the democratic rationale The normative right of Lyme patients to democratic decision making was expressed by the chair of the invitational conferences: In a way you can now no longer conduct research without involving the target group in it. [ . . . ] The usual norm in our society is that of patient participation. --- [Chair of invitational conferences] Giving Lyme patients a voice in the research about the disputed case definition of Lyme disease was broadly approved, but it was contested whether merely involving patients also incorporated democratic decision making in the national research agenda for Lyme disease. Well I think that, as such, [the involvement of Lyme patients] has been a good initiative. [ . . . ] But saying that what was discussed [at the invitational conferences] will from now on constitute the national Lyme disease research agenda is of course slightly odd. [Researcher] This researcher's objection was that Lyme patients were too limited a group of citizens to decide on the public health issue that the researcher thinks Lyme disease is. This opinion was supported by the reference made to the democratic rationale by a member of the program committee. Civilians do think very differently than patients do. [ . . . ] If you should ask someone from the general public, so a civilian who doesn't yet have the disease, how you can avoid getting [Lyme disease]? For a civilian that is a relevant question. --- [Member of the program committee] The researcher-implicitly-agreed that a more comprehensive democratic approach would do more justice to the complexity of Lyme disease and the broader research scope needed to tackle it effectively. If I'm right the word prevention is not mentioned in [the funder's] research programme. How is that possible? How on earth is that possible? [ . . . ] As a researcher, I can't understand that at all! But I do understand why this happened. [ . . . ] What use is a vaccine to people who currently have Lyme disease? That doesn't cure today's Lyme patient. So I can understand that from the patients' point of view. [Researcher] . For communities, empowerment relates to intensified integration, trust, citizenship and democracy and to the reinforcement of structures, networks and health promotion efforts . For participants, involvement may also provide opportunities to express political identity and belonging . In research, PPI conforming to the transformative rationale has the potential to strengthen disadvantaged and disempowered groups by giving them a chance to speak out on research issues . Transformative involvement seeks to overcome discrimination and oppression , to ameliorate social inequities and to promote fairness, emancipation and empowerment . This may require negotiating a balance between developing valid generalizable knowledge and benefiting the community , e.g. through egalitarian deliberation . The presence of the transformative rationale in the Lyme research case is illustrated in Box 3, suggesting that this rationale was endorsed by both the funder and the patient associations. --- Substantive In general, the substantive rationale is based upon epistemic considerations, i.e. regarding theories of knowledge . Substantive involvement seeks the inclusion of more diverse, extensive and context-specific bodies of knowledge, in order to increase the quality of the information underlying decision making . It assumes that non-experts see problems, issues and solutions that experts miss . The resulting higher quality of information may also improve the quality of the decisions themselves ). In a research context, substantive PPI refers to the inclusion of lay theories, experiential knowledge, local knowledge and the importance of context , with the aim to improve the quality of knowledge as the main research output . By adding such insights to the design, methods and findings of the research , substantive PPI produces new and more reliable, credible and valid knowledge . The exchange betweenand integration of-various perspectives, approaches Box 2: Illustration of the consumerist rationale Accounts of the run-up to the research program and the invitational conferences reflected a consumerist rationale, with patients and researchers as opposing stakeholder groups promoting their respective interests and imposing their perceptions on each other. That is, the patients entered 'the market place' with predefined issues stated in their petition. Our petition consisted of eight points, [for instance] about better registration of Lyme patients, in-service training of doctors, development of better tests, more research into chronic Lyme disease, more attention to the opportunities for treating chronic Lyme disease [ . . . ]. --- [Representative of patient association] Against these consumer rights, the researchers raised and defended their 'undisputed' research findings. What struck me was [that these] rather deviant opinions about the interpretation scientific research were raised very forcefully. [ . . . ] That some from the patient movement very definitely rejected certain scientific research findings. [ . . . ] And they include examples where I think well, if you just really brush aside the outcomes of well-designed scientific research [ . . . ] well, then it sometimes becomes a challenge to keep up a useful discussion. [ . . . ] That is then often part of the final 10 percent that you can't agree on. [Researcher] and bodies of knowledge, one of which is scientific knowledge , produces valid representations of social phenomena and a socially robust, holistic and shared understanding of research problems and objectives . Giving lay participants a say in the formulation of research questions promotes relevant research which is meaningful to the Box 3: Illustration of the transformative rationale From the perspective of the funder, the rationale for patient participation in the research program was transformative. The funder expressed-implicitly-the opinion that chronic Lyme patients, who had been closely involved in drafting the current case definition of Lyme disease, were 'wrongfully' excluded from having the disease by that very definition. Hence, for the funder, the aim of patient involvement was to do them justice by taking them more seriously. We are now going to draw up the research agenda, and what is important for us now is to identify the problems that are currently causing the undesirable situation in practice. In the end, we want to achieve a situation in which patients are correctly recognized and identified. That problems are taken seriously, that they get appropriate treatment. [Staff member of funder] Here, chronic Lyme patients are portrayed as a marginalized group for which fairness is promoted, and patients indeed felt supported by the funder's actions in line with this transformative starting point. So we then went and talked to [the funder]. And then we were listened to. [ . . . ] And [the funder] took that seriously and very . . . [The funder] took a step back to be able to do so. And that process was addressed very carefully, to get everyone around the table. [ . . . ] to see whether it was possible to start a dialogue. --- [Representative of patient association] Box 4: Illustration of the substantive rationale The substantive rationale was reflected by-among other things-substantial changes made to the research proposals, which reflected the integration of patients' experiential knowledge with scientific knowledge. One example was the inclusion of Lyme patients who did not meet the prevailing case definition for the disease. We really changed the study design to accommodate this. [ . . . ] We hadn't done so based on our initial line of approach, as we thought well look, we want to study Lyme disease, but we need to be sure that these people do have Lyme. [ . . . ] And looking back on it I think we were right not to stick to this, and also include patients who could not be said with certainty to have Lyme disease, but who were suspected of having it. --- [Researcher] Another example of the integration of patients' experiential knowledge was the adoption of an additional diagnostic test, which was regarded by the researchers as not yet validated, and which had so far not been released by its producer for further validation study. It did work out well, as we're still trying to, we're going to examine some tests and we already have three [valid tests], and we're trying the fourth [not yet validated] one. And by having the patients involved, it turns out to create some momentum that will enable us to also include this fourth test. So that's funny in a way. So that's what I thought afterwards, as I was a bit apprehensive about it at first. [Researcher] communities affected by the issue being studied . The presence of the substantive rationale in the Lyme research case is illustrated in Box 4, showing how knowledge integration occurred in the design phase of Lyme studies. --- Instrumental In general, the instrumental rationale refers to involvement as a means of achieving particular goals, such as health and wellbeing by increasing the efficiency and/or effectiveness of policies, programs and services in health or health promotion . The policy goals themselves are not open to discussion . Instrumental involvement may also contribute to cost-effectiveness through the use of community resources , meaning it may involve costs for citizens . In research, the instrumental rationale offers a pragmatic justification for PPI , with the involvement serving as a means to an end . In terms of effectiveness, instrumental PPI makes science more sensitive to societal problems , which increases the usefulness of the knowledge created . It also increases the likelihood that changes take place and real progress is made on the problem under investigation . In terms of efficiency, instrumental PPI increases the acceptability, legitimacy and ownership of the research process, its outcomes and the solutions of problems studied . Therefore, it also enhances the legitimacy for an agency to act upon the study findings . In research practice, instrumental PPI can support the recruitment of peers , the access to marginalized groups and the retention of participants in studies . It may include the co-building of frameworks, tools and strategies , and the improvement of other research products . Finally, lay participants may provide the motivation and capacity to disseminate research information to peers , and to assist the implementation and dissemination of research finding . The presence of the instrumental rationale in the Lyme research case is illustrated in Box 5, showing how patient contributed to the feasibility and efficiency of Lyme studies. --- DISCUSSION --- Summary In our critical review, we identified five categories of underlying reasons for PPI in research. The democratic rationale reflects the normative right of citizens to have a voice in research that affects them. The consumerist rationale refers to the economic right of stakeholders with interests to have a say in and demand the best research. Rooted in social justice, the transformative rationale seeks to empower marginalized groups by giving them a say in research. The substantive rationale is based on epistemic considerations and aims to improve the quality of knowledge that research generates. The instrumental rationale is of a pragmatic origin and refers to improved efficiency and effectiveness of the research. The practical examples from a case study on PPI in a research program on Lyme disease in the Netherlands demonstrated the simultaneous presence of all five rationales. --- Limitations The first limitation of our overview of rationales is that we largely followed the classifications made by the original authors. As a result, the categories we distinguished still have overlapping features, i.e. the-in principlerights-based rationales also include consequences that link up with the substantive or instrumental rationales . Alternatively, we could have reduced each category to its core, by splitting up the original definitions and by allocating the different parts to these most discriminating characteristics. This could also have led to subcategories, such as individual and community empowerment as part of the transformative rationale. Such more sharply defined categories could yield even more clarity about the underlying reasons for using PPI in research. Further refinement procedures should preferably include research groups from a variety of scientific domains, as we saw how different domains identified different rationales in their typologies . In our experience, agreed-upon criteria for the intended core rationales might be essential, although it may still require discussion to apply these criteria consistently. The second limitation is that our categories of rationales may not be complete. As critical reviews are usually not as systematic as other types of reviews , we may have overlooked relevant publications on typologies of rationales for PPI. Nor can we exclude the possibility that other researchers would have made different decisions on which papers to include in-or exclude from-the overview of typologies of rationales . In other words, critical reviews are necessarily subjective due to the interpretation needed for the appraisal, synthesis and analysis of the literature . For instance, one of the papers we excluded due to a lack of conceptual clarity distinguished an additionally coercive rationale , to reflect the critique that public involvement in research provides opportunities for powerful interests to manipulate the decision process and silence opposition. Although this coercive rationale was on average not endorsed by the US general public , its presence could be context-specific, and its added value thus worthwhile to explore further. A final limitation lies in the broad scope of our critical review. We included publications on PPI in research and in policy and practice, from the domain of health promotion and from other domains, and from a period covering more than 30 years. However, we neither systematically compared the articulation of rationales from different contexts, domains and points in time, nor did we conduct an in-depth analysis of the participatory research practices that were covered by the publications included in our review. The number of empirical studies that explicitly make use of rationales in the evaluation of PPI in research seems too small to conduct such comparisons or in-depth analyses. Issues like these could be interesting to explore further once more eligible studies have become available. --- Interpretation We have demonstrated the applicability of the five categories of rationales in a case study on PPI in Lyme research. Although outside the domain of health promotion, the applicability of different rationales for PPI in research has also been shown in three multiple case studies . These revealed that rationales seldom become manifest in pure form . First, different participants within one case can endorse different rationales . In the Lyme research case, for instance, we saw how the funder initiated the involvement of patients to do them justice Box 5: Illustration of the instrumental rationale The instrumental rationale became manifest in the patients' involvement in the design and the conduct of the studies. The first example, about the burden to patients of participating in the study, relates to the study's feasibility. Sometimes just very practical things. [ . . . ] I think with the proposal about this PET scan they had the idea that they wanted to do everything in one day at the intake. So then the patients said, well, isn't that a bit too burdensome for these Lyme patients. [ . . . ] It sounds great, but [...] you might have to divide it over two visits, or whatever. [Representative of patient association] The second example, about speeding up the inclusion of patients, primarily refers to the efficiency of the research process, while it may ultimately also help improve the study's effectiveness. Of course we're still starting up the study. So we were able to brainstorm with the patients about how we want to facilitate the inclusion further, and it's always good to be able to discuss that with them. [Researcher] Currently they're having trouble recruiting enough patients during the first six months. Actively contributing ideas about how we can communicate everything through the patient society. To get people to join the study sooner. [Representative of patient association] , while the chair of the invitational conferences invited them in order to give them a voice . To give another example, in a study on transdisciplinary research projects, the funding agency expected stakeholder involvement to contribute to implementable outcomes , while scientists thought that the best motivation for stakeholder engagement was knowledge integration . These findings additionally imply that the extent to which different rationales are being endorsed within a single case may differ between research cases . Second, the dominant rationale within cases may vary over time . In the Lyme research case, for example, we recognized knowledge integration during the design of the research, while efficiency reasons tended to occur particularly during the conduct of the research. Another example stems from the study on transdisciplinary research: almost all project activities gradually also came to serve implementable outcomes , while these activities initially followed other rationales . These empirical findings highlight the presence of multiple rationales for PPI in research, which runs the risk of creating mismatches between the expectations of-and thus conflicts between-the different participants . Hence, PPI is dynamic, and carrying out PPI is about managing the different underlying reasons that patients, public and other stakeholders may contribute. To allow for such management, the different rationales should be noted, explored and made explicit . We feel we can claim that our categories of rationales may serve as a frame of reference in this respect. Starting from the-potentially conflicting-means or ends they aim for , each rationale for PPI in research is expected to have its own implications for the design of the dimensions of the participatory process . This dependence was illustrated in an analysis of participatory knowledge production practices, where different rationales led to different framings of the designation of the participants , their selection and what they were expected to provide . The example of the democratic rationale from our Lyme research case additionally shows the potential influence of the 'participatory playing field' on such dimensions. That is, 'what' may determine 'who' should be involved, such as, in our case study, involving the general public rather than patients in drafting the research agenda for the prevention of Lyme disease. These findings confirm previous hypotheses and earlier empirical insights that highlighted the importance of 'intentionality' for PPI -be it in research, policy or practice -and the advisability of distinguishing between patients and the public in this respect . Therefore we agree that, in order to substantiate the potential of PPI in research, its underlying reasons should be made explicit from the start and be regularly reflected on during implementation . We think that our overview of rationales may guide the anticipated discussions in this respect. --- Implications Although it is not a panacea, our overview of rationales can offer added value for the implementation, evaluation and conceptualization of PPI in research. First, it may support implementation by taking it as the-currently lacking-starting point for the substantiation of the available indicators for successful PPI . This may prevent PPI from becoming 'nominal', meaning that it solely serves as window dressing , for instance, because it is started in response to conditions for research funding . Such nominal PPI may be fairly prevalent, as one of the most cited challenges for PPI in research is the concern about tokenistic involvement . Second, using our overview to clarify the rationales present in participatory research could support the joint development of an impact pathway hypothesis, in order to facilitate the implementation of PPI . This may enhance the positive and avoid the negative impacts of PPI in research as well as provide better opportunities to assess its added value . The fact that most previous evaluation studies of PPI in the research were found to be poorly theorized , indicates that, at present, the greatest progress might be made by carefully conceptualizing PPI in future participatory research. Third, using our overview could provide more coherence to the-so far fragmentary-concept of PPI in health promotion research . If combined with dimensions of the participatory process , evaluation studies recognizing different rationales could provide a better understanding of how to connect the why of PPI with the type of patients and/or public to involve, how to involve them, in what, and what they are expected to bring . --- CONCLUSION Our critical review yielded five conceptually different categories of rationales for PPI in research. Together, these may be used as a frame of reference to explore, make explicit and reflect on the different rationales in health promotion research. This might help to manage the dynamics of the participatory process, define realistic purposes, select matching approaches and design appropriate evaluation studies. These evaluations, in turn, may improve our understanding of how different rationales relate to the dimensions of the participatory process, and thus contribute to a more coherent conceptualization of PPI in research. Any effort to further extend or refine the categories of rationales we distinguished should preferably involve research groups from different domains. --- SUPPLEMENTARY MATERIAL Supplementary material is available at Health Promotion International online.

In health promotion research, enthusiasm for patient and public involvement (PPI) is growing. However, a lack of conceptual clarity leads to ambiguities in participatory processes and purposes, and hampers efforts to achieve and evaluate PPI in research. This study provides an overview of its underlying reasons-or rationales-so as to better understand, guide and interpret PPI in research practice. We conducted a critical review to identify typologies of rationales for PPI. We re-categorized the different types of rationales from these typologies based on their content. We illustrated the resulting categories of rationales with examples from a case study on PPI in research on Lyme disease. Five categories of rationales for PPI were identified. The democratic rationale reflects the normative right of citizens to have a voice in research. The consumerist rationale refers to the economic right of stakeholders with interests to have a say. Rooted in social justice, the transformative rationale seeks to empower marginalized groups. The substantive rationale starts from epistemic considerations and aims to improve the quality of knowledge that research generates. The instrumental rationale is of pragmatic origin and refers to improved efficiency and effectiveness of the research. Our overview of categories of rationales can be used as a frame of reference for PPI in health promotion research. Exploring, stating explicitly and reflecting on the underlying reasons for PPI may help to define realistic purposes, select matching approaches and design appropriate evaluation studies. This might also contribute to the conceptualization of PPI.

INTRODUCTION What is Community OR? The literature does not easily characterise what it is, leading to a range of distinct claims . It seems that its origin lies in the space between developing an enhanced OR that serves to improve society and a practice that serves to support the community . Pioneering work can be seen from Ackoff's work with leaders in the black community in Mantua, USA , Cook's work in Aston, Birmingham, UK , Eden et al's work with charities , and Beer's work with the Allende government of Chile . After an explosion of interest, a number of clusters of applications have sprung up , including work in housing , health ), poverty , and sustainability . It seems that the extant literature on Community OR involves the application of methods in an enhanced way to problems in which interests of underrepresented or vulnerable populations in communities are the main concern, and for which solutions to these problems are difficult . One of the main consequences of these projects has been to give voice to the communities' concerns . Yet, over the last decade or so there has been a growth of online communities engaged in knowledge and information-sharing, largely through discussions and conversation on social media that has become a dominant form of giving voice to community issues, yet these have been almost entirely ignored by Community OR scholars. An online community is a community facilitated by social technology , comprising a spectrum of forums, which include markets, auction sites, bulletin boards, social networking sites, blogs, gaming and shared interest sites . Some common features of these things are that participation is radically distributed and part or most of the activity is done online or through digital means . Technologies have been developed to offer alternative forms of collaborative engagement. Researchers and practitioners alike are keen to understand the emergence and implications of online communities . Online, people have increasingly based their societal identities on their interactions through social media, and have developed fairly well-defined behaviours. These are non-geographically bound communities, based on a structured set of social relationships among communities of interest. Our labelling of these as 'communities' is rooted in the construct of a community as a network of social relations marked by mutuality, social bonds and social exchange . Thus, scholars have described online communities in terms of what citizens are seeking, such as networking with fellow enthusiasts, and finding solutions to problems; or interest, relationship, and transaction; or professional opportunities. However, OR has been slow in realizing the new capabilities arising from the novel ways disadvantaged or excluded communities are actively coming together online to tackle problems of concern. Although there is a growing stream of research on the increasing importance of online communities in social life , the problem is that it may be difficult to define "Community OR" in this online world. It is hard to understand why Community OR has not addressed these new forms of working with citizens. It seems that this would be the sort of opportunity that its pioneers, such as and Ackoff , would have welcomed, where citizens become more actively involved as participants in their democracies, with the governance and decisions that emerge from this process being more democratic and more effective. This builds on the premise of OR as social science , with a progressive aspect where it is claimed that engaged citizenry through OR practice is better than a passive citizenry drawing on . The emphasis from a Community OR perspective is that the participation process is a transformative tool for social improvement. In this paper, we aim to address this lack of attention to the new ways of working and broaden the notion of Community OR to include problems associated with communities identified by their online communications. However, there is a need to build on the foundational work on Community OR and make the case for studying online communities as a legitimate group to analyse in order to form a better understanding of the role of OR in this type of setting. In order to do this, we position our work theoretically in relation to social constructivism and social materiality. In doing so, we draw on Actor Network Theory and developments by Callon of the Co-production of Knowledge Model . These perspectives enable us to take a broader and nuanced view of community action. In particular, these perspectives provide the means to identify how, and in what way, we get a convergence of collective action in online communities. Methodologically, our approach is built on important work in OR that has defined constitutive definitions for Soft Systems Methodology , for interpretive systems approaches , and generically for Problem Structuring Methods . The role of a constitutive definition is to provide a behavioural or performative description of a methodology to substantiate epistemic claims for their use. To make sense of empirical data from on-line communities we set out a similarly constructed constitutive definition for claiming that the behaviours observed can be classified as Community OR. For our empirical work, we are interested in the mobilisation of online citizens in response to risk and disaster. Such situations are highly dynamic and located specifically, both spatially and temporally, leading to a greater need for understanding relational coordination. We show, in relation to a specific disaster in 2015, how and in what way the collective commitment of an online community to the framing of the problem was built up and reinforced across episodes of socially constructed events and in the relationship between different forms of actors' expertise, characterised as either traditional/technical or non-technical/'lay'. In particular, we use the findings to explore questions of how communications, decision-making and the self-organizing process operated during the disaster response and discuss implications for OR practitioners . Using social media data from a real situation, we analyse how individual actors framed their circumstances in communication with one another and how this affected their subsequent interpretation and decisions as the disaster unfolded. In particular, we aim to observe patterns of altruistic reinforcing behaviours in conjunction with the emergent problem solving approach of the online communities as a response to the disaster . It is the appeal to widening participation, the utility of online communication, and the limitations that expert facilitated participation entails, that prompted the idea that on-line communities might be a suitable way forward for conceptualising Community OR, and that the advantage of the massive reach of social media might be coupled with new affordances for active community action to achieve this. However, considerable issues arise with respect to facilitating and moderating asynchronous and distributed modes of interaction in these settings. Not least, the difficult question of the original motivation to use an online platform without the prompting action of attending a workshop and the efforts of the academic/practitioner/expert facilitator to animate the methodology; i.e. how is the problem mediated? This is a key research question, originally raised by Morton, Ackermann, and Belton on how the issues that arise in moderating such distributed interaction differ from the issues involved in facilitating a traditional PSM/Soft OR workshop, that we also address. In sum, having set out a likely scenario of relevance to Community OR practice and our theoretical and methodological position, we set out to establish our contribution -that we can observe, through publicly available social media data, behaviours that can be classed as Community OR. We thus open up the field of Community OR to empirical study through a new route, which has implications for OR practice generally and how OR practitioners might engage with communities in the future, especially in response to events such as natural disasters. --- THEORY DEVELOPMENT The study of Community OR is no longer synonymous with a sole focus on specific organisational forms , and nor is it driven solely by a moral imperative demonstrate a wide range of motivations for practitioner engagement). Instead, we think that we need to broaden the notion of Community OR to include online communities. However, these forms of community are not susceptible to the traditional or prevailing views of what Community OR involves. We feel these views do not explain well the drivers for forming online communities, and nor do they provide adequate prescriptions for the practice of OR. Below, we provide a brief review, starting with a stock-take of normative views of Community OR. We then build on recent work on the Generic Constitutive Definition and from the sociology of science in order to develop a constitutive definition for Community OR. The logic for this development is summarised in a set-based viewpoint presented at the end of the section. --- 2.1. Normative Views Midgley and Ochoa-Arias have edited together a useful selection of previously published and new work, and they draw specifically on normative visions of community and ideas of context and future development . They debate a normative definition of community and present an in-depth analysis of what is meant by the label community and the social construction of the field of Community OR. They suggest that Community OR practice is defined by its orientation to an ideal that is itself defined politically. Their vision for Community OR sets out three political traditions against which Community OR can choose to align its practice -liberalism, Marxism and communitarianism. Their case for a normative definition is argued in order to set a boundary around what is considered as belonging to the Community OR discipline. Further, they point to possibilities for a broader definition of community than the received liberal/capitalist tradition, which they consider to be a dangerous default. Their argument is grounded in the need to make explicit how the practitioner's political orientation affects their approach to client selection, setting boundaries for inclusion and exclusion, and choice of methods. Whilst we agree that the political orientation of the practitioner does indeed affect these decisions, the arguments of Midgley and Ochoa-Arias do not help to place an emphasis on everyday exchanges with regard to social interactions as the focus of enquiry. Their account also sees actions as being based on rules or norms. Instead, we suggest the basis for a definition of Community OR should be in theories that have an interest in understanding and exploring actors' activities, interactions, interventions and performances. Further, these theories should be based in a socially materialist view, in the sense that interventions must be understood and investigated as a material as well as a social reality . We are also striving to understand interventions as structured, emergent and creative. For this, we locate our interest in a pragmatist account of action that focuses explicitly on the view that the experience of actors is produced by purposive socially mediated actions and emotions, and is tempered by the material arrangements that embed these activities . See also Taket and White . --- Actor Network Theory In order to do this, and also to widen the scope to include analysis of how a problematic situation and stakeholder group coalesce and develop a participant-led process to intervene, we draw on the language of translations and the concepts of problematisation, interessement and enrolment derived from Actor Network Theory . ANT was first brought into use in understanding Soft OR interventions by White , and in OR more generally by Keys . Our definitions follow : • Problematisation -the initial co-creational process of linking a problematic situation with relevant stakeholders into an actor network consisting of both human and non-human actants. Questions emerge from the problematisation that become the goals that the actor network seeks to resolve through taking action. • Interessement -negotiating the self-interests of the actors so that they are "locked into place" in addressing the problematic situation. • Enrolment -defining and coordinating roles as worked out during interessement, such that actors accept them. Interessement is thus successful if this is achieved. Scholars have already acknowledged the central role of the concepts drawn from ANT in understanding behaviours in actor networks in the complexities of vulnerability and resilience of communities in disasters , and we here show how further developments in the ANT field can contribute to the examination of a definition of Community OR. In order to do this, we also draw on 'The Co-production of Knowledge Model' defined by Callon . This model arises from his critique of the ways that the scientific community have engaged with publics in the "production and dissemination of scientific knowledge." According to Callon, "Technoscience is pervasive; it invades daily life and consequently becomes the subject of heated debates and controversies." He asserts that failure to manage the process of engagement, and in particular deal with the unintended consequences of technoscience developments, has led to a "great divide between specialists and nonspecialists" and thus to a crisis in trust. Callon identifies three modelsof the participation of nonspecialists in "scientific and technological debates" : • The Public Engagement Model : Scientific knowledge is viewed as objective and universal, lay knowledge is considered worthless, and specialists must teach non-specialists everything and have nothing to learn from them. Publics do not participate in knowledge production and only control it indirectly. Emerging technoscience is seen as a "source of progress" . Mistrust, arising from unintended side effects of this progress and subjective perceptions of risk, lead to resistances. Public engagement is thus directed towards overcoming these resistances. • The Public Debate Model : Scientific knowledge is still seen as objective and universal. However, unlike the case of the PEM, this knowledge is now seen as incomplete due to its "abstraction" from reality and its location purely in the laboratory. The process of "broadening the circle of actors addressing the issue of technoscience and its applications" leads to the formation of differentiated publics, employing a range of methods such as inquiries and focus groups to manage the relationships. These processes "muddle the usual boundaries between specialists and non-specialists" but do not remove them. In fact, they provide forums in which the earlier-mentioned resistances can now be voiced. However, whilst apparently legitimising the inclusion of non-specialists, the PDM falls short of full representation due to the divided nature of the publics created by the process. • The Coproduction of Knowledge Model : Here, the role of the non-specialist is essential, as the specialist forums of divided publics and specialists are replaced by hybrid forums of concerned groups . Knowledge is now dynamically produced by the close cooperation of specialists and lay expertise. Callon specifically uses the notion of the concerned group as engaged in a process of "collective learning" . • Specialist knowledge is still required, but now it is framed in a way that makes it "particularly rich and relevant" . Callon et al. recognise that the knowledge of experts is not the only knowledge possible, and in relation to the three models above make the distinction between the traditional laboratory-based research of the scientist and what they call research "in the wild" . The latter involves, not just the co-production of new knowledge, but also, and simultaneously, the co-production of new "social identities" where "new knowledge must be acquired and shared, and new ways of thinking, seeing, and acting must be developed, pooled and made available" . Thus, it is likely to be the case that evidence of the CKM in operation in hybrid forums is where we will see examples of translation from problematisation into action through interessement and enrolment. Observing such translations empirically in an actor network requires a means of looking at the behaviours of the actors. --- Behavioural, Performative Views We now develop an action-oriented approach to our definition from a behavioural, performative perspective to define Community OR in situ before we provide the empirical lens we have chosen to use to verify our approach. Following the approach of Yearworth and White in the construction of a Generic Constitutive Definition for Problem Structuring Methods , we have set out to adopt the same process to produce a similar constitutive definition for Community OR. In sum, the GCD was constructed behaviourally, in that it sought to provide a classification schema for labelling problem structuring behaviours in action. It is thus also performative in nature ); a researcher seeking to establish that problem structuring is being enacted need only establish empirical evidence for a set of behaviours for confirmation. This removes any requirement for self-identification or self-labelling with any known PSM by the actors enacting those behaviours . It therefore becomes solely a concern of the researcher observing those behaviours to supply the label. ), so we have concentrated on the performative aspects of community as discussed by Parry and Mingers in order to construct ours. We have skimmed over the OR component of the definitions. The question of whether an activity labelled Community OR is OR seems a less important point. The planning case cited by Parry and Mingers was readily classified by them as Community OR, and the key expertise afforded to the target group was provided by a physicist challenging the environmental impact models that the developer was using to justify the planning application that the target group objected to. We have assumed that a Community OR engagement is almost certainly dealing with a mess and thus it is a reasonable assumption that PSM-like behaviours would be in evidence. We acknowledge that we could have chosen some other set of behaviours with which to define a recognisable OR activity taking place, perhaps associated with quantitative methods, although these are myriad and less easy to categorise behaviourally. The performative idiom, itself emerging from ANT, recognises agency as residing in both human and non-human actants. However, White et al. point out that human actants are imbued with the property of conscious intentions such as motivation, unlike non-human actants whose purpose is manifest purely through their physical nature e.g. flood waters acting according to their nature to damage homes and property, whilst human actors are motivated to prevent that from happening. Any definition of Community implies collective human agency , even if the action manifest by that human agency is only sharing an understanding or belief in something, possibly mediated through the agency of non-human actants. We argue that the community becomes observable as a phenomenon once that shared belief or understanding is translated into actions exists in the minds of its members and they start to act as a group), which give rise to empirical data. As researchers interested in group activity phenomena, we should be able to observe and theorise over these empirical data. Therefore, our constitutive definition of community is broad and covers any group activity of human actants with a shared understanding or belief in something, who then take actions that are observable in response to that belief or understanding. We bring this definition into the realm of OR and narrow the scope of observable actions by invoking the specific notion of action to improve a problematic situation. This provides us with the first test of whether a phenomenon is considered in or out of membership of OR practice -are the actions we observe empirically recognisable as OR in practice? Yearworth and White have argued for a behavioural answer to this question around the practice of Soft OR, and we believe that we have shown that the extant Community OR literature illustrates that the something causing the formation of a community wanting action to take place is invariably a messy problem. Therefore, in response to the messiness of the problem context, we would expect to see evidence of problem structuring behaviours as characterised by the 9 elements of the Generic Constitutive Definition for PSMs . The element definitions of the GCD are summarised in Table 1 and the element labels are used later in the coding of data in Table 3. --- Element Label Element Definition 1 Action to Improve Problem structuring is intervention oriented and leading to improvements in a problematic real-world situation through a set of purposeful activities 2 Systemic Approach Use of systems ideas , which are i) appropriate to context, ii) theoretically adequate, and iii) supported by appropriate systems modelling 3 Adaptation/ Creativity The approach taken was adapted or elements combined for the particular problem situation, requiring human creativity 4 Methodological Lessons Given that any problematic situation is unique, learning from the intervention is focussed on methodological lessons arising from conscious reflection 5 Worldviews The process of problematisation recognises that problems are construct of an individual's mind and defined by their worldview, they do not exist independently of human thought. --- Messiness The problem context in which the approach is used has been recognised as messy, wicked or swampy. 7 Interactive/ Iterative/ Therapeutic The intervention in the problem situation has come about through sharing of perceptions, persuasion and debate in a participative group setting using an approach that is iterative and "interactive/therapeutic, and not expert 8 Subjectivity In the approach taken it has been recognised that the stakeholders of the problem situation are part of it, and cannot be objective. 9 Limits Conceptual limitations have been recognised in the approach taken, including building expertise in the use of problem structuring Table 1. The 9 element labels and element definitions of the Generic Constitutive Definition for Problem Structuring Methods . --- Motivations and Self Organisation There is a need for a further theoretical positioning so that we can begin to question the centrality of the role of the OR practitioner's interventions. We do this because there is still a need to stress the importance of focusing on power relations, conflicts, and interest . The focus is on a field where actors produce and reproduce differences and inequalities. Our aim, therefore, is not to focus on the individual practitioners and their norms, but to imagine the field as relational and dynamic, which embodies the complexity of real-life interventions. Therefore, the next aspect of our constitutive definition concerns the question of motivation. What is motivating a group of people to take action? Midgley and Ochoa-Arias identify the motivation of the facilitator as a significant force in Community OR. Whilst criticising the default and implicit "political, moral and religious" drivers behind this motivation, they seem less concerned with the selforganising nature of a target group and how it might be considered as a community of interest. For us, the latter is of central importance, as it is to Herron and Mendiwelso-Bendek . Self-organisation appears to us to transcend formal political motivations as a more fundamental principle, although we accept that groups emerging from a process of self-organisation in response to a shared need will inevitably acquire a "political, moral and religious" complexion, either as part of that emergence, or from the need itself, or indeed imported through the agency of, for example, a community leader or the Community OR practitioner. However, that does not detract from the focus on self-organisation in our definition. Our constitutive definition thus questions the centrality of the OR practitioner in a Community OR process by placing emphasis on the activities within an emerging target group. The origins of the intervention, in an OR sense, start from the target group rather than the instigation of an OR practitioner. In the case described by Parry and Mingers , a pre-existing target group is augmented by the assistance of an expert modeller, leading to the increased effectiveness of the group activity, which involved objecting to a planning application. We return to the simple ideas of 'vulgar competence' in OR practice and the 'science of better' and advance the case that the meaning of better and what is competent are a property of, and emerge solely from, the behaviours within the target group . We thus replace the need for a normative view with a constitutive view. This view is necessarily pragmatic , focussing on the immediate needs of the target group rather than political ideals; and it is performative ) in concentrating on the behaviours and processes involved in the group activity that emerges to meet those needs. By introducing the principle of self-organisation into a definition of Community OR, we can turn the problem of labelling on its head and return to some of the egalitarian and emancipatory goals of the origins of Community OR and ask a new question: should we find evidence of Community OR taking place as self-organising problem structuring, would it not be of value for OR practitioners to offer their services to help? The marrying-up of the OR practitioner and a community in this situation then becomes a peer-oriented activity more in keeping with the idea of Callon's CKM. We return to this question in the later discussion, where we consider this from an ethical perspective. --- Decentring Facilitation We now draw attention to the role of the facilitator in our definition of Community OR. Is a facilitator necessary for Community OR to be taking place? This is a difficult question to answer since, for the majority of Soft and Community OR practice that we know about, it is the role of the practitioner as a facilitator that has brought to light the interventions through academic publishing. Here we make use of the idea of decentring. In their analysis of the use of an online Group Support System for problem structuring, Yearworth and White de-centre the role of the facilitator and comment on the possibility of facilitator-less GSS and self-organising problem structuring behaviours. They conclude that there is no particular technical reason that would prevent such a group activity taking place. Therefore, it is the GSS itself that provides the scaffolding for problem structuring behaviours. In the same way, we argue that the digital platform for online communities thus now becomes an important actant in its own right as part of an actor network. It follows from this that the possibility of facilitator-less Community OR, scaffolded by a digital platform, is plausible. We bring these strands together and present a novel solution to the conceptualisation of a Community OR engagement and approach to the collection of empirical data -we shift our entire empirical focus into the domain of the study: i.e. the intersection of social media and community needs. We reframe our research questions in a way that is open to empirical investigation by the collection of data from social media to look for possible instances of Community OR emerging in accordance with our constitutive definition. Thus we arrive at the notion of a Community OR engagement as purely a construct derived from observational data, rather than one of expertise coming into a community in the form of an academic practitioner/expert facilitator bringing about an engagement . In making this leap, we do not need the action of the academic/practitioner/expert facilitator for problematisation, interessement and enrolment to occur for our community; there is no actual Community OR engagement as defined through the eyes of an academic practitioner/expert facilitator, although the scenario may be labelled as Community OR ex post, as we are setting out to show in this paper. The crucial step is that the translation from problematisation through interessement and enrolment is viewed as self-initiating and self-organising steps in the creation of an actor network. We consider that the activities of such emerging target groups on social media should be considered as part of the domain of Community OR and a legitimate object for our study -and, crucially, an object for our support as OR practitioners. --- Summary We can summarise our argument for a constitutive definition of Community OR observable in social media by the use of a set-based view similar to the approach of Yearworth and White and shown in Figure 1. We define the superset of all collective behaviours arising from a problematisation and leading to action . We regard this superset as containing all OR practice generally , which in turn contains the subsets of Soft OR , and Community OR . Yearworth and White clearly established that non-codified PSMs are a subset of % , and our argument above thus reduces to the assertion that & ∩ ' ≠ ∅. We then introduce our empirical claim that a subset of can be mediated by digital platforms 2 and, furthermore, that a subset of this activity is conducted on social media and is publicly observable . This leads us to a restatement of our theoretical and methodological position that & ∩ ' ∩ 0 ≠ ∅. For the rest of the paper, we make use of this set notion as shorthand, both to indicate our constitutive definition for Community OR and our assertion that this is not an empty set. --Figure 1 here - This section has established the theoretical and methodological bases for our constitutive definition of Community OR, defined the logical relationship between Community OR, non-codified PSM behaviours and their mediation via social media, and set out our analytical framework in the sociology of translations and CKM. In the next section we present our empirical work based on a major event that occurred at the end of 2015. --- METHOD AND DATA Our empirical work is centred on the devastating impact of an Extratropical Cyclone on communities in the Northwest of England and the Scottish Borders in December 2015. The storm formed on the 3 rd of December over the Atlantic Ocean, traversing in a North-Easterly direction. The UK Meteorological Office named the storm on the 4 th of December, and at 2pm on the 5 th of December issued the following 'Red' weather warning: This warning, which includes the specific phrases "Red 'take action' warning" and "significant impacts", signal the initial temporal boundary for our data collection. 2 We explicitly identify this subset because we refer to the example of using Group Explorer by Yearworth & White later in the Discussion, which is characterised by the region % ∩ ~' ∩ ~& ∩ 6 ∩ ~0 as shown by the crosshatching in Figure 1. --- Approach Our approach set out to i) establish the existence of a target group for analysis consistent with our constitutive definition for Community OR, and ii) provide the empirical data to support the analysis through the theoretical lens of translations and the CKM. It is based on the use of publicly available data from Facebook and Twitter, and is structured in four different phases reflecting the different affordances of the platforms and motivations for participation as follows: 1. Quantitative analysis of Twitter data: to provide initial insight into the short-term dynamics of the problem context, network structure, and emergence of any target groups, There was a certain amount of to-ing and fro-ing between collection and analysis of social media data, and this is an inherent feature of our methodology. Therefore, these phases summarise the exploratory nature of our investigation and do not prescribe a rigid, step-by-step procedure. --- Ethics of Data Collection and Analysis The data collected from Twitter and Facebook are available via the search terms shown below. Since we are looking for patterns of behaviour, we are not recruiting participants to a study and sampling is in effect completely determined by the queries used to search for data. By definition, as stated in §2.6, if the queries submitted to a platform return no data, then 0 = ∅. The availability of the data to searching is governed by the agreement between the users who post information and the platform providers, as specified in the terms and conditions of the respective End User Licence Agreements . Since publicly visible data are being analysed, and there is no specific recruitment of human subjects, we therefore conclude that this is not human subject research from a research ethics perspective . Also, there is no prima facie case for any participant to expect privacy when posting information via these platforms, unless the user takes specific actions to restrict visibility of the information they are posting . In the case of the event we analyse, the fact that the data is public is essential to the spontaneous creation of the target group we study. We return to ethical questions in the discussion. --- Quantitative Analysis of Twitter Data The Twitter data were used in the initial analysis due to the manageability of data produced, limited by the smaller number of Twitter users and the 140 characters limit in Tweets. The Twitter data were obtained using the Advanced Search facility on the twitter.com website, via the use of a client application written in Python based on the use of the Tweepy package. The initial Twitter query looked at the volume distribution of Twitter data from the 3 rd of December to the 3 rd of February 2016 using the search phrase "Carlisle AND flood* since/2015-12-03 until/2016-02-04". This query generated 1641 tweets, of which 455 mentioned other twitter accounts and were therefore suitable for network analysis. Inspection of data from this initial search led to the generation of a further search after it was seen that the hashtags #spiritofcumbria and #spiritofcarlisle had emerged, on the 7 th and 9 th of December respectively, and were being used for communicating, in a more focused way, reactions to the needs generated by the flooding and storm damage. Searches on these two hashtags generated 2827 tweets combined, with 1357 suitable for network analysis. The volume of tweets downloaded from the Twitter searches over the data collection period is shown in Figure 2. The initial Twitter query revealed a very sparse network, as shown in Figure 3. The network graph extracted from the Twitter query on the hashtags reveals a more developed morphology, and is shown in Figure 4. --Figure 2 here -- A number of network parameters were extracted from both graphs and are summarised in Table 2. Although this shows a more cohesive social network emerging from the use of the spirit hashtags , as is clearly shown in Figure 2, the volume of tweets dies down to almost zero by the 3 rd February 2016. At this point in time, the network as identified by both the search term and the hashtags has ceased to exist in any meaningful sense. It is clear that, whilst the Twitter data provide some limited view into the actor network around problematisation, for this problem context we were not able to follow the translation through interessement and enrolment to self-organisation and to problem structuring behaviours, reflecting the findings of on motivations for participation. However, we should not be surprised because the triggering event associated with the search term has ceased to be the problem at hand. analysis. The analysis focused on three distinct phases in the period of data collection, which we have labelled as follows: --- Network 1. Preparation, which starts from the original 'red' warning at 2pm on the 5th of December and ends when the Carlisle flood defences begin to fail towards midnight -much earlier than expected by the Environment Agency, --- 2. Emergency Response, which starts as soon as the flooding begins, and --- 3. The Rally, which has no fixed starting point, but is where we identify the beginnings of community-organised responses to the flooding, rather than responses being led by the Emergency services, Government agencies, or Not For Profit organisations. --- Preparation The initial tweets on the 5th December were mostly passing-on general area flood warning messages: e.g. "People at risk in Carlisle should have been warned about flood threat if they are registered on the @EnvAgency system". However, some tweets were targeted at very specific locations: and "Thoughts with people of #Carlisle. Flooded out again. Brand new flood defenses failed. How much money wasted". By the morning of the 6 th , we were waking up in the UK to widespread media reports that major flooding was underway in Carlisle. --- Emergency Response Most of this phase of the disaster corresponds to three main groups of expertise mobilising to deal with the immediate threat of the flooding to human life. We would not expect there to be much traffic on social media except where citizens, and particularly news media, are observing them in action. In the first group, the normal UK emergency services were being augmented by specialist organisations with requisite equipment, such as Army troops for infrastructure defence: "Critical that flood defences around electricity sub stations in Carlisle / Kendal not breached. Army brought in to help. #CumbriaFloods". Also, rescue efforts were being augmented via the Royal National Lifeboat Institution : "@PwllheliRNLI volunteer and @RNLI Flood Rescue volunteer Bryn Ellis in the thick of the action in Carlisle pic.twitter.com/I7xKbc8O9f". The second group, Government Agencies, such as Carlisle City Council, are less in evidence. At this critical time, we would expect them to be providing assistance and coordination to the first group, but for these actions to be largely unobservable through social media. A check of the @CarlisleCC Twitter account activity on the 6 th December revealed mainly replies to tweets rather than originating messages. This check also uncovered the fact that their website was down due to the impact of the flooding on their own infrastructure: "@allaboutclait Hi Andrea, apologies for the delay in responding, yes, the website is offline Due to the flooding of the Civic Centre". A critical member of this group, The Environment Agency, only appears in the Preparation phase as a source of warnings derived from their flood prediction models, and they were an object of anger and frustration as already noted. In this phase, their expertise is not being called for. Concerning the third group, Not For Profit Organisations, we would not expect to find them assisting directly in this phase, although on the 7 th we find reference on the morning of the 7 th . However, the role of the rescue services is diminishing as the flood waters recede. Carlisle United's ground was a highly visible symbol of the scale of the flooding when the water levels "nearly reached the crossbars on the pitch" at Brunton Park . The "Blues" were quick in organising community action, and there were many media reports on Facebook as early as the 6th December publicising their offer of help to the community. For example, this on the Guardian website: "A lot of concern from the lads about all those affected by this weekend's events up in Cumbria and the Borders. Every member of the squad has agreed that they want to help … It has been agreed that we will all be available, after training on Tuesday to help out in any way possible. Clearing furniture, cleaning, tidying -anything that is needed and that will help. Contact us if you think the lads can help you with your situation". However, despite the publicity via news outlets, there is no evidence in either the Facebook or Twitter data to indicate that this offer grew into self-organising and on-going activity. The necessary translation did not take place: problematisation was nebulous and interessement and enrolment apparently did not happen. There is evidence in the data for two further self-initiating activities. On the 3 rd January 2016, there is a post on Facebook referring to an open meeting organised by the Lions Club International: "Carlisle -are you missing out? Flood hit communities across Cumbria are benefiting from the support of Lions Clubs International -Carlisle is missing out and we would like to do something about this with your help. For those interested, there will be an open meeting on 12th January, 7pm". The post is invitational and promises an "open" meeting. However, there is no further data that indicates what happened at the meeting or after. On the 4 th of January, there is a post referring to "Floods HQ Milton Hilltop" and a link to a blog post with reflections of a volunteer starting on the 21 st December with the initial task of packing Christmas hampers for families affected by the flood with items donated by local supermarkets. Again, this seemed self-limiting to the specific task of distributing Christmas hampers without any further sign in the data of self-organising activity. For both cases, again, the necessary translation did not occur. On the 7 th January, a brief post on Facebook by the "Carlisle Flood Action Group" referred to a meeting apparently to be held that evening: "Thanks to Roy and team @CrownMitre for gifting their Here we see the beginnings of a self-organising activity where non-time-bounded action to improve the situation is seen as a guiding purpose. The creation of an action-oriented identity on Facebook reflects this translation. The socio-materiality of the situation is also acknowledged in that the target group recognises that the situation has been caused by inadequate flood defences and that this inadequacy arises from decision-making processes and interpretation. The process of finding a voice seems bound to a translation from being passive victims needing help to active citizens seeking not just answers -presumably from suitable experts -but more importantly, change in how things are to be done in the future. --- Qualitative Analysis of Initial Facebook Data To follow the emergence of this group, our analysis -from the point of view of questions about problem structuring behaviours -is based on the Facebook postings from the Carlisle Flood Action Group from December 12 th 2015 onwards, as only 3 further posts were found in the original Facebook data through to the 3 rd February 2016. A new PDF file of 173 pages/22.2Mbytes was generated, which was simply the download of all data from the Facebook page https://www.facebook.com/CFRBAG/. We also draw attention in the data to the problem context and the nature of assemblage of actors, interpreted as an example of a hybrid forum and CKM in action. The analysis of this data set is presented in Table 3. "Update: The Group following their meeting felt it wise to change the name to "Carlisle Flood Action Group" but are at pains to say this is focused fully on representing Carlisle and its districts, residents and businesses. Hope that is OK friends." Adaptation/creativity. Interactive/ Iterative/ Therapeutic. Table 3. Concept mapping of the data covering the formation of the Carlisle Flood Action Group --- Date The data and concept mapping presented in Table 3 cover the formation of the Carlisle Flood Action Group in its first two months of existence. Problematisation, interessement and enrolment are clearly established, indicating the necessary translation into self-organising and self-sustaining activity. As can be seen in the data, certain aspects of the GCD can be seen, although it is missing evidence of taking a systemic approach and the data clearly cover a period much too early for any thoughts of methodological learning. However, the group is being reflective and showing a willingness to listen and adapt. It is clearly making use of 'conventional' workshops and meetings, and recognises the role, and power, of social media in supporting its activities. Unfortunately, there are no available data from the workshops, although there is reference to audio recordings from the 7 th January meeting being available in Dropbox these were 'Not Found' when an attempt was made to access them. Social media are clearly instrumental in on-going problematisation, interessement and enrolment. They also serve as the glue to bind the group together in on-going exploration of the problem context, and they provide a rich source of worldviews . This glue also generates a rich narrative structure reminiscent of the sort of OR case data called for by Ormerod ; we are seeing evidence of iteration and adaptation in approach, perhaps in far more detail than we would normally have access to in OR engagements. There are also signs of the CKM emerging in the data. It seems clear that the relation between traditional expertise and lay expertise is still in the mode of Public Engagement and Debate Models rather than full CKM . However, the group clearly see themselves as a source of expertise that needs to engage in dialogue with traditional expertise as represented by bodies such as DEFRA and the Environment Agency. In summary, we believe we have established that the activity described in this case can be viewed as Community OR in action, as set out by our constitutive definition established in the Theory Development section. --- Quantitative Analysis of Facebook Data The Text Analytics module from IBM SPSS Modeler v18.0 was used to analyse the Facebook data from the Carlisle Flood Action Group Facebook page at https://www.facebook.com/CFRBAG/. The data were extracted and transformed using the Facebook Graph API and a custom Python script coded using the urllib2 and json modules. The 'message' part of the post and the date were extracted from the downloaded json data structure and written to an MS-Excel spreadsheet as an intermediate format for use with SPSS Modeler. There were 379 messages to the Carlisle Flood Action Group page in the data structures returned from the Graph API query during the year after the initial post made on the 12 th December 2015. Category models were built interactively with the 'Basic Resources ' loaded and using the extracted results to build categories. However, the process was not completely automatic and required manual 'cleaning' to override the automatic category assignment. Given the exploratory nature of the analysis performed, and the relatively small size of the data set3 , the global frequency of concepts chosen was set equal to one. Due to the prevalence, and importance to the problem situation, of the use of EA or E-A in the posts in reference to the 'Environment Agency', a global substitution was made in the data before loading into SPSS Modeler. Running the SPSS Modeler stream found 3,296 concepts in the data. The category builder in the interactive workbench was then used to build a category tree. Whilst this is nothing more than a taxonomy of the concepts found in the data, SPSS Modeler preserves the link to the location within the source data, which in this case is bounded by the message data structure in the post. This co-occurrence mapping is similar to coding in Computer Aided Qualitative Data Analysis Software such as NVivo with the coding boundary set to paragraph and using a matrix query over the codes . . The 'category web' that can be extracted from any one particular category can be interpreted as a view of the actor network for categories corresponding to specific actors, or actor classes, when the lowest level categories are chosen for display. As an example, the actor network for the actor class 'flood barriers' is shown in Figure 5, and for 'flood victims' in Figure 6. In the key to both figures, the quantity "# docs" refers to the number of messages in which the categories appear. --Figure 5 here -- This approach opens up innovative angles for exploring the actor network as the category web presents the graph of category relations bounded by a single message posted by someone to the Carlisle Flood Action Group Facebook page: i.e. it is the human actor that posts the message who is implying that a relationship exists between categories, as labelled by SPSS Modeler, by the fact that they cooccur within a particular posted message. However, whilst providing a novel approach to the visual exploration of the actor network, there is no apparent solution to the problem of labelling behaviours according to categories that exist outside the data themselves; nor is there available a pre-built 'Resource Template' suitable for the task. Best practice seems to indicate that the typical starting point for automated text analytics are data that have already been behaviourally labelled, most likely through the process of capturing the data . A Resource Template could have been built, ironically, starting from the manual behavioural coding already carried out in the qualitative analysis of the Facebook data shown in §3.5. This would be useful for analyses of further data sets in the future, but not for the existing data i.e. all the data we have extracted and analysed in this paper could have been used as a training data set. We envisage the possibility of qualitative analysis for particular types of behaviour in ever larger data sets used to build a 'Resource Template' that could then be used in SPSS Modeler for the automated behavioural analyses of new data sets. --- DISCUSSION The data are rich with images that graphically convey how the community was actually created by this devastating flood . The event was both highly dynamic in time and highly specific in terms of location. This could be seen in the Twitter data shown in Figure 2, where there was an initial sharp delineating time boundary on the 5 th December followed by a decay to under 50 tweets a day by the 19 th December, and then a fairly steady decline to almost zero by the 3 rd February 2016. However, the consequences of the flood continue to unfold in the affected community, as evidenced by the volume of messages posted to the Carlisle Flood Action Group Facebook page. Dealing with flooding is undoubtedly a wicked problem , and the immediate post-event response in this case, whilst involving a wide range of expertise, was not dependent on the deployment of intellectual capability in the form of an academic/practitioner/expert facilitator from the OR community. However, we believe that we have convincingly demonstrated through our analysis that Community OR was in action despite this absence. We have charted the emergence of one new community organisation in our qualitative analysis -the Carlisle Flood Action Group -that represents the translation of the original problematisation, interessement and enrolment of actors into a group that was to all intents and purposes engaged in problem structuring, even though those actors would probably not have heard of the term. There was wide engagement and participation from citizens, and that has been evident despite the presence of existing, and the emergence of new, organisations. We view this self-initiating and self-organising behaviour amongst actors as the very embodiment of what is meant by a community. However, our concern here is less about definition and more with the question of community empowerment. Have social media empowered the community and helped them structure the problem as created by the event? In answer, we have mainly focussed our analysis of the degree to which we have seen evidence of OR behaviours and the CKM emerge in the empirical data. We find support for our observations in the work of Tim et al. , who describe the emergence of social media as boundary objects in their analysis of a disaster response. Their qualitative case study research describes how social media were used in the 2011 Thailand flooding disaster and demonstrate the "enactment of social media as a boundary object-in-use" . They present data that clearly shows communities problem structuring their response to the event. Although their research is oriented towards promoting the practical application of social media platforms in disaster response situations, their findings nonetheless lend further support to our argument that & ∩ ' ∩ 0 ≠ ∅. In addition to the idea of social media scaffolding OR behaviours, discussed in §2, the findings of Tim et al. and our analysis in §3 lead us to the strong conclusion that social media platforms are actants in their own right in actor networks. --- The Relationship Between Soft OR and Hybrid Forums Once the immediate community needs had been addressed, focus naturally started to switch towards the mitigation of future events, which cues the entrance of other expertise in the form of expert modellers such as those skilled in providing predictive models of flooding. Examples of hybrid forums grounded in notions CKM already exist 2016), who draws attention to possible equivalence of purpose and form between a problem structuring workshop and the hybrid forum . In our analysis in §3, we focus specifically on the translations evident in the case data from the perspective of both hybrid forums and CKM. Here we are particularly interested in how the CKM applies to decision-making situations, where scientific knowledge and technology capabilities cannot completely 'solve' a problem due to limitations such as restrictive budgets and imperfect knowledge of local conditions. Responses to flooding and the construction of flood defences fall into this hinterland of messiness. We can illustrate the divide between traditional and lay expertise with the observation that, in our data, the non-specialists regarded the Carlisle flood defences as having failed, but to the expert, they had merely 'overtopped' -the word 'failure' was reserved for the case of actual physical collapse. To bridge this gap, the CKM lens helps us to see the role of non-specialists as essential: publics are now part of a "concerned group", and the problem of trust is finessed by the fact that know-how in the problem situation is now on an equal footing, so the concerned group can "gain recognition for their actions". The non-specialist as a member of a community affected by a disaster and emerging new social identities -such as the Carlisle Flood Action Group -can be seen as part of a wider group acting to improve the problematic situation. The Carlisle Flood Action Group amply fulfils the definition of a hybrid forum. In this "space of organized hybrid forums" Callon et al. regard controversy as the causal mechanism that "…allows the design and testing of projects and solutions that integrate a plurality of points of view, demands, and expectations. This 'taking into account', which takes place through negotiations and successive compromises, unleashes a process of learning" . The parallels with problem structuring behaviours in bridging between different worldviews and subjectivities are apparent and striking. In our data, this controversy is focussed on the technical role of the flood defences, the expertinformed decision-making leading to their construction after the 2005 floods, and the aftermath of their failure or "overtopping" . In fact, dealing with contested terminology and the modification of vocabulary in hybrid forums allows "laypersons to enter into the scientific and technical content of projects in order to propose solutions" . They observe that "Relations between specialists and non-specialists usually bear the stamp of asymmetry" and one of the ways in which expert groups maintain their power is through their specialist language. The language of hybrid forums and specifically the concept of dialogical democracy now provides us with a link -in effect a restatement and continuation -to the original goals of Community OR as set out in the Theory Development section. Here, in contrast with familiar 'representational' democratic processes, the focus is on mechanisms that enable dialogue between traditional and lay expertise characterised by the intensity, openness and quality of the debate . We can thus bolster the motivational argument for our constitutive definition of Community OR by aligning the self-initiating and self-organising behaviours observed in the data with this concept of dialogical democracy , andCronin, Midgley, andSkuba Jackson , for discussions of the importance of dialogue to problem structuring). --- The Development of Digital Platforms The analysis of the data we presented in §3 has shown that translation through problematisation, interessement and enrolment are taking place, mediated by the use of social media, so the preconditions for Community OR activity have been established: i.e. & ∩ ' ∩ 0 ≠ ∅, and the use of distributed interaction through an online platform is already central to the behaviour of the actor network . Further examples from Sebastian and Bui , the 2013 floods in Germany , and the Queensland Police Service demonstrate how social media platforms are being used in disaster scenarios and clearly show problem structuring by participants. There is no question that social media can be treated as an actant in the emerging actor networks resulting from such scenarios. We expect to see social media platforms playing a greater role in the future, leading to further sources of empirical data in the region & ∩ ' ∩ 0. This leads us towards new research questions relating to problem structuring behaviours mediated by social media: 1. To what extent do social media scaffold problem structuring? 2. What is missing from current social media that, if were they to be incorporated, might improve problem structuring? 3. What is required from social media to enable OR practitioners to engage with a concerned group? The automated text analysis of Facebook data presented in §3.6 shows the beginnings of the sort of automated analytical tools that might be deployed to explore these three questions further, although they fall short of the quality of analysis presented in Callon's original work or the work of Brewer et al. ; lacking both the capability to generate abstract concepts from the data and, crucially, to show the role of the social media platform itself as an actant in the actor network . However, our questions are practically oriented and, in answering them, we can dispense with the theoretical constructs employed in this paper to establish the existence of Community OR. Therefore, from the examples we have seen so far, we can advance tentative answers to these questions. On the questions of scaffolding and what is missing, there seems to be enough evidence that the capabilities of Facebook in its current form are already sufficient to afford problem structuring behaviours. The experience of Morton et al. on implementing PSM workshops online, i.e. working in the region % ∩ ~' ∩ ~& ∩ 6 ∩ ~0, shows that there is nothing intrinsically flawed in the idea that social-media platforms could act in the same way as specialist software such as Group Explorer if they were suitably modified; i.e. widening scope to the region % ∩ ~' ∩ ~& ∩ 6. Recent work by Yearworth and White demonstrates the practical decentring of the role of facilitation and suggest that it is not unreasonable to see the "rise of a participant-led group decision support process model" . However, this sort of extension might not be required. The findings from , that social media can act as a boundary object, suggest that actors are actually already sharing mental models as might be expected in a PSM workshop. In the on-going posts of the Carlisle Flood Action Group we did find a link to a 'forum' , that includes reference to the use of models in a process of debating and learning: "Use this forum to post topics about the technical aspects of the rivers and flooding. This could involve historical information, recommendations, statistics, models. Please note this is an opportunity to debate and learn. Whilst we may put forward recommendations to the appropriate authorities we are not expecting to fully solve such a complex issue" . However, judging by the lack of activity on this forum and its demise, it appears that the main activities of the Carlisle Flood Action Group, that are mediated digitally, are actually taking place on the social media platform itself. Taken together with the findings of Tim et al. , this suggests that enhancements to existing social media platforms are perhaps unnecessary and might be ignored even if they are provided. The answer to the third question is simple. In constructing the argument for the claim that & ∩ ' ∩ 0 ≠ ∅, we required that problem structuring behaviours mediated by social media were publicly observable, and that these were resulting from a collective problematisation and leading to action: i.e. 0 ⊆ ". In §3.2, we made the observation that the public nature of the interactions between actors was necessary to achieve a translation from problematisation through interessement and enrolment. We therefore suggest that nothing more is required from existing social media platforms to enable OR enact CKM-like behaviours in hybrid forums could be unsettling and challenging places to work. These implications for practice suggest a new direction for Community OR: an ethical reframing of practice that reflects the new and dynamic power relationships that social media afford online communities. Unlike designed Community OR interventions, where issues of stakeholder inclusivity and power are considered by the OR practitioner leading the intervention , here we are suggesting that the OR practitioner needs to negotiate entry into an emerging concerned group to achieve a satisfactory enrolment. Established OR competencies will either have to be re-packaged in new guises or practitioners will have to find new ways of working . The three strands, discussed above, suggest fruitful directions for future work. --- CONCLUSIONS We started out in this paper by implying that there remain difficulties in defining Community OR, where very few of the papers on the subject actually tackle directly the issue of where common ground lies. We have added a new definition of Community OR to the debate with two characteristics: i) a self-initiating, self-organising actor network showing spontaneous problematisation and enrolment in response to a triggering event, and ii) evidence of problem structuring behaviours leading to actions to improve the problematic situation consistent with the Generic Constitutive Definition of PSMs by Yearworth and White . From this definition, we can thus re-conceptualise Community OR as a construct emerging from data, in addition to the conventional view of an OR engagement initiated by an academic practitioner or expert facilitator. We see social media playing an instrumental role in two ways: providing both the source of empirical data to observe this new form of Community OR, and providing the scaffolding through which it occurs. Our analysis has shown that current social media platforms are not limiting problem structuring behaviours, and there is a certain amount of urgent catching-up required by the OR community, in general, to engage with concerned groups as they emerge. We therefore see social media providing new possibilities for community empowerment and participation, with consequences for social enterprise, democratic processes and citizenship. Actor Network Theory, and specifically hybrid forums and CKM, have been shown to present a new and encouraging theoretical basis for the analysis and development of OR engagements generally, but especially in the realms of Community OR and Soft OR/PSMs, where lay expertise is likely to be ever more present. The emergence of hybrid forums online would seem to be a natural milieu for a range of OR competencies, thus presenting the challenge to the OR practitioner of how and when to engage. --- practitioners to engage with a concerned group. Although not included in our original treatment of Callon's work, we introduce here his notion of the "mobilisation of allies" and remark that it is up to OR practitioners whether they become part of the translation from problematisation through interessement to their enrolment in the actor network. The negotiation of their role would proceed through becoming aware of concerned groups coming into existence in response to a triggering event, and then engaging with the group through the social media platform. This sits very well with the ambitions for OR expressed by Ackoff and Rosenhead , discussed in §2.4, as well as the desire to serve 'non-traditional' target groups that are participatively organised and led . --- Summary In our Theory Development section, we reviewed the Community OR literature and touched on many of the same concerns as expressed in the CKM/hybrid forums work, although these clearly come from two separate academic communities. The link between them appears in the concept of dialogical democracy . Its characterisation is theorising at a sociological level and largely descriptive . However, we need more than this for a contribution to Community OR of practical importance. Therefore, we see the implications of our findings for practice having three strands; 1. The OR community generally, not just Community OR, has work to do in catching up with the rapid pace of developments in online communities that are already exhibiting distributed problem structuring behaviours and the de-emphasis of expert facilitation. We have clearly shown that social media already support self-organising and self-supporting "concerned groups" of the CKM , able to translate from problematisation through interessement and enrolment, leading to practical action. This catching-up is urgently required. 2. We have to accept that social media afford communities the freedom to engage and disengage with issues at will. Therefore, concerned groups can be very dynamic entities. Established ideas of power and emancipation in Community OR need to respond to this new dynamism and take into account a more nuanced understanding of power relationships and the role of the OR practitioner in an online setting. We refer to work on the relationship between Communities of Practice theory, Foucault's work, and ANT as an example of how achieving this understanding might be approached . 3. Self-organising and self-sustaining online communities raise new ethical issues for all OR practice, and not just Community OR, especially in relation to the trust relationship between specialists and non-specialists. For specialists such as OR practitioners used to PEM/PDMlike public engagements and legitimisation of decision making, online communities that

We develop a new constitutive definition of Community OR as a self-initiating, selforganising community actor network emerging spontaneously in response to a triggering event and showing evidence of non-codified OR behaviours leading to action to improve the problem situation. From this new definition we have re-conceptualised Community OR as a construct that can be empirically observed emerging from suitable behavioural data. Social media play an instrumental role, acting as both the source of data and the enabling mechanism through which this form of Community OR occurs. Social media afford new possibilities for community empowerment and participation, with consequences for social enterprise and citizenship. We use Actor Network Theory, and specifically the language of translations, hybrid forums, and Callon's Co-production of Knowledge Model (CKM), as the methodological basis for our definition and analysis. The appearance of hybrid forums as a selforganising response to community needs after an event would seem to be a natural milieu for a range of OR competencies. However, unlike traditional practitioner-led engagements, here the OR practitioner's competency enters in a supportive rather than leading role. We support our argument through the analysis of social media data arising from the community response to a devastating flooding event -the Carlisle floods of December 2015.

Introduction In this study we focus on assimilation as what immigrants do that might enable some of them to assimilate while others do not. In the past 40 years there have been immense numbers of economic studies that have focused on assimilation. With the exception of studies of labor supply, however, all of these have examined the outcomes of the process, not the process itself. Thus Chiswick's classic cross-section analysis focused on wage changes accompanying time spent in a new country, as did Borjas ' and analyses of artificial cohorts. Other work has expanded the examination of the outcomes of the process of assimilation to focus on both prices and quantities . Substantial work has also focused on employment of immigrants . These outcomes are the indicators of immigrants' well-being, and they provide signals to potential immigrants ; but they tell us nothing about what immigrants are doing in the process of assimilation itself. Here we step back from this black-box approach to assimilation and focus instead on the process of assimilation-on what immigrants actually do. We develop some facts describing immigrant-native differences in the use of time; based on these facts, we derive an economic theory of assimilation that has specific testable predictions about the behavior of immigrants compared to natives. We test these predictions on a large recently created American data set, the American Time Use Survey. After having examined these hypotheses we consider the sources of heterogeneity in immigrants' outcomes. Finally, we replicate the results on an Australian data set. Although one recent study has examined immigrants' time use and two others have analyzed time use by ethnicity, our focus on assimilation as a process is novel for economists. But although new to economics, viewing assimilation this way has occupied historians and others for a very long time. 1 Handlin's classic discussion framed the "immigrant experience" as one of becoming rather than being, with assimilation viewed as a learning process: Working as they did in a new fashion and in a strange place, it took time to find a way around, to begin to learn the operations of the productive system of which they had become a part. 2 Some Initial Impressions Since 2003 the U.S. has developed the world's largest continuing data set based on time diaries, the American Time Use Survey , which samples respondents from households that had recently left the Current Population Survey sample. We use data from 2004-2008, containing diaries provided through next-day recall by nearly 65,000 individuals ages 15 and up, each for the one day prior to the morning on which they completed the diary . Each person keeps a diary for only that one day, thus preventing us from looking at anything other than snapshot differences between immigrants and natives. There are 55,949 natives in the sample and 8,976 immigrants. With the appropriate weights we obtain a complete picture of what the representative American, immigrant or native, was doing on a representative day during these five years. The ATUS' restriction to one household member prevents us from examining within-family behavior, and the restriction to one diary-day per person rules out consideration of differences in habitual or long-run behavior between immigrants and natives. The data set does, however, provide a sufficiently large sample of immigrants and enough additional information about them to enable us both to draw conclusions about immigrant-native differences and to examine the underlying causes of any implied differences in the costs of assimilation. 2 The ATUS classifies activities into over 400 separate categories, with the biggest threesleeping, paid employment, and watching television-accounting for over 60 percent of total time. Most activities are not engaged in by most respondents: The representative native averages 24.5 separate activities each day, as does the representative immigrant. This preponderance of zeroes means we cannot concentrate on a small set of primitive categories, since immigrant-native differences in participation in the activity would be tiny. We focus instead on ten aggregates of activities: Purchasing, education, market work, care for others, 1 The role of learning and time use in assimilation has been recognized in song: Leonard Bernstein, Candide, "I am so easily assimilated, …, It's easy, it's ever so easy! Do like the natives do." 2 While all the results reflect population-based sampling weights in the ATUS, one might be concerned about unit non-response. It is true that in terms of observables this is not a problem in the ATUS, but perhaps the sample is nonrepresentative along non-observable dimensions. We obviously cannot account for this potential difficulty; but, if it exists, one would think that those immigrants who, other things equal, are less likely to have completed time diaries are those who are most different from natives. That being the case, the results here will understate the true immigrant-native differences. eating/drinking, household activities , personal care, other leisure, socializing/television watching, and organizational/civic/religious activities. For the first three of these aggregates, the three that we examine in most detail, the Appendix lists the sub-aggregates that comprise them, along with the average amounts of time in the most common subaggregates. 3 In creating these aggregates we recognize that the task of classification is essentially arbitrary. For example, sleeping is clearly personal care; but is going to church a religious activity or socializing? Should eating/drinking be a separate category, or is some of it more properly included in work, as in a business lunch, or in socializing, as with a dinner with friends? In the end, as with the use of any accounting data, we are thrown back on the choices about classification made by the producers of the data. Consider the raw differences in patterns of time use between immigrants and natives. The first row for each of the ten categories in Table 1 presents the mean amount of time in the activity by the average immigrant . Looking at these unconditional means suggests that there is no difference in time spent in many activities by immigrants and natives. The mean amounts of time spent in purchasing and education, for example, are nearly identical; and there appears to be no particular pattern in the other differences. 4 The second and third rows of each part of the table present the fractions of sample members engaged in the activity and the conditional means of time spent on it by those engaging in the activity . These patterns reveal a richer picture of immigrantnative differences. Consider, for example the purchasing category: The unconditional means are equal. Immigrants are less likely to undertake the activity, but their intensity in it exceeds that of natives. On the other hand, the unconditional time spent in organizational activities is greater among natives, but that is entirely due to their greater incidence of this activity-the intensities are the same. In these activities the distinctions are clear, but even in others the table demonstrates the need to go beyond comparing unconditional means. --- Theoretical Motivation We construct a theory of assimilation that highlights the distinction between incidence and intensity of time use. Assimilation is an investment process-the immigrant does things that natives do not need to do in order to learn more about the new country and "fit in better" in the future. To capture this process parsimoniously, let there be two time periods, t = 1 and 2, and two types of individuals, natives and immigrants . Some of the things that an immigrant does aid assimilation. Taking a course in English, dealing with the transportation system, working outside the ethnic enclave, and shopping in non-ethnic stores all increase the immigrant's familiarity with the new society. Conversely, other activities, particularly those performed at home, and those that involve dealing with other immigrants of the same background, are not assimilating. Let there be two types of activity, assimilating activities, a, and other activities, a fraction 1a, together making up the total amount of time available, set equal to 1 for convenience. 3 One might be concerned that these activities include travel time. To exclude travel time would exclude something that is clearly endogenous. Nonetheless, we re-estimated the basic models reported in this study with travel time excluded, a re-specification whose results altered none of our conclusions qualitatively. 4 The time diary method requires total times to exhaust the day-1440 minutes. Because a few categories could not, however, be coded, the sums of these averages do not quite exhaust the total: Among immigrants they total 1422 minutes, among natives 1419 minutes. Assimilating activities require overcoming the language and cultural hurdles of getting out into the native world. The Foreigner's maximization problem is: where 0 < U 1 , U 2 < ∞ for 0 ≤ a t ≤ 1; U 11 , U 22 < 0. R is the discount factor, 0 < R < 1. The gain to engaging in the assimilating activity is increased utility in the future, with the magnitude of the gain depending upon the function F, F>0, F'>0, F"<0. I is an indicator function equaling 1 if a 1 > 0, 0 if a 1 = 0; and each immigrant incurs the lumpy cost C of choosing to overcome the hurdles of undertaking the assimilating activity. The parameter C varies across immigrants-some find it easier than others to leave the comfort of their familiar culture and take part in activities that are foreign to them. We have assumed that the costs of participating in the assimilating activity are independent of the amount of the activity that is undertaken. This is probably a simplification-some of these costs no doubt are also variable, rising as the amount of the assimilating activity increases. Nonetheless, so long as some part of the cost is fixed, the predictions of the model are valid; and the presence of variable costs adds no other testable predictions. Maximization by the immigrant in Period 1 yields: Now consider maximization by the native. We assume that the native's costs of undertaking the assimilating activity are identically zero-C ≡ 0, and that there are no gains to assimilation-F ≡ 1 for all a 1 ≥ 0. The native has, by definition, already assimilated, so that the fixed costs are always greater for the immigrant. The utility-maximizing choice of activity in Period 2 is identical for both natives and immigrants-all that differs, assuming that U is the same for both, is the fillip to utility generated by the fact that F <1 for immigrants. Given the shape of U, in this simplified model the native will always undertake some of both the assimilating activity and the other activity; and the right-hand side of will be identically zero among natives ≡ 0 for them). We can thus focus on differences in outcomes in Period 1 between natives and immigrants. Recognizing that C is a random variable, rewrite the equation describing the immigrant's decision about undertaking the assimilating activity as: and remember that this probability is identically one for natives. Comparing between immigrants and natives, whatever the maximizing choice of a * 1 is for natives, the negative term on the right-side for immigrants means that, if they choose to undertake any of the assimilating activity, the amount chosen will exceed that undertaken by natives. --- The model yields two major predictions: 1 The assimilating activity is less likely to be undertaken by immigrants than by natives. That is more likely to be true if the costs of assimilation C are higher, the gains to assimilation, F -F, are lower, and the immigrant has a shorter horizon . --- 2 Conditional on both engaging in the assimilating activity, the immigrant will choose a higher a * 1 than the native. In addition to these two broad implications about immigrants in comparison to natives, one can go further and proxy some of the parameters to consider how outcomes will change with variation in immigrants' characteristics, linking those characteristics to C. Thus: 3 Immigrants who have been in the new country longer will be more native-like, as will those from countries that are more similar to the U.S. Their probability of engaging in assimilating activities will approach that of natives, and, conditional on engaging in these activities, the amount they undertake will approach that of natives . --- 4 Older immigrants, conditional on the time they have lived in the new country, will have a lower probability of engaging in the assimilating activity, because for them Period 2 is shorter. The model outlined above describes "long-term" behavior, with an immigrant's lifetime in the destination country partitioned into two broad stretches of time, an initial period in which assimilation takes place , and a subsequent period in which no further assimilation occurs . In this context, choosing not to engage in the assimilating activity represents a decision never to engage in this activity during the years of the initial assimilation period. Long-term non-participation along these lines might make sense for two of the assimilating activities we study below: education and work. The other major assimilating activity that we study, however, is purchasing, and it difficult to believe that an immigrant would never shop over an extended period. Moreover, the data we analyze provide time-use information only for a single, randomly chosen day for each individual in the sample. Non-participation in these data does not necessarily represent the long-term concept described by the preceding model. Rather, it represents the short-term decision to forgo the assimilating activity on the survey day and perhaps undertake it on other nearby days. To provide a closer link between our theory of assimilation and the empirical analysis to follow, consider an immigrant for whom the long-term utility maximization problem outlined above implies an optimal choice of a * 1 > 0 for the amount of assimilating activity undertaken during the initial assimilation period. The immigrant must now choose how to allocate this aggregate amount of time across the shorter time periods that make up the longer assimilation period and that we observe in the data.5 Let a 1d represent the time allocated to the assimilating activity on day d of the D days that make up the assimilation period. We can then write the immigrant's short-term time allocation problem as choosing the a 1d to: Here, u is a daily utility function, c represents the fixed cost of engaging in the assimilating activity on a particular day, and I is an indicator function for a 1d > 0. 6 If the fixed costs c were zero, concavity of the utility function would yield an optimal solution of spending the same time on the assimilating activity every day . With sufficiently high fixed costs, however, it becomes optimal to concentrate the assimilating activity on selected days and completely forgo it on others. The higher the daily fixed costs, the greater the incentive to concentrate assimilating activity on fewer days, and therefore the trade-off between incidence and intensity of time use that emerged from the long-term model reappears in its short-term counterpart. In both models, fixed costs of participation are the source of this trade-off. Of course, both immigrants and natives are likely to face daily fixed costs of participating in various activities. These fixed costs will tend to be higher for immigrants than for natives, however, perhaps because of poor English proficiency, unfamiliarity with host country customs, and other factors that make social engagement more difficult for them. We examine all of these potential reasons in the empirical work. Moreover, fixed costs of participating in assimilating activities will be especially high for immigrants relative to natives, because such activities require substantial engagement with society at large, which can be more difficult and uncomfortable for immigrants. Holding constant the overall amount of time spent in such activities , the assumption of higher fixed costs for immigrants yields the prediction that they engage in assimilating activities less frequently but more intensively than natives. In other words, immigrants will undertake these activities on fewer days per week, but on the days when they do participate in themthey will spend more time on them. Similar implications pertain for comparisons among identifiable groups of immigrants expected to vary in their fixed costs of engaging in assimilating activities . The extension of our theoretical model to short-term time allocation decisions establishes a direct link between the model's predictions and the empirical analysis that follows, because the data refer to time use on a single day. 7 Although in some respects the long-term and short-term versions of the model have similar implications, the short-term model provides a clearer interpretation of our findings for an assimilating activity that all individuals engage in at some point. Because eventual participation in this activity is 100 percent, there is no long-term trade-off between the incidence and intensity of time allocated to it. In the shortterm however, there is the possibility of doing it less frequently but for longer hours per trip. The short-term model predicts that immigrants will do this in order to mitigate their higher fixed costs of engaging with the host society. --- Basic Results To move to the empirical analysis we first need to consider what activities might be called "assimilating." The process of assimilation involves using one's available time partly to invest in learning about the native culture, economy and environment. We need to define which activities can appropriately be classified as assimilating. We arbitrarily assume that three activities-purchasing, education and market work-are included in this list, while the other activities are not and can be called non-assimilating. In the end, however, the best test of what is an assimilating activity is whether it is characterized by the one-day immigrantnative differences in behavior suggested by the theory. For those activities that we believe to be assimilating we cannot tell whether the time spent by an immigrant in the activity eases him/her into the native world. For example, a work activity may take place in a sweatshop where the immigrant worker is surrounded by his/her fellow immigrants who speak the same language, and where s/he deals with a foreman in that same language. Alternatively, eating and drinking may occur in a workplace where the immigrant is surrounded by natives. While the ATUS does identify the location of an 7 We thank a referee for suggesting this extension of the theoretical model. activity and the presence of others, these identifications are only provided for some of the activities; and it is not possible to identify the immigrant status of any other people present when the respondent engages in the activity. While we could provide a quick informal test of the theory using the means in Table 1, a consideration of the immigration literature and the descriptive statistics suggests this would be misleading. Immigrants are significantly younger than natives: While 23 percent of natives are under age 18 or over age 64, only 13 percent of immigrants are. Immigrants are much more likely than natives to be Hispanic, much less likely to be African-American, and much more likely to be married. They have many more children at home than do natives, and those children are disproportionately likely to be preschoolers. Immigrants are much less likely than natives to have gone beyond high school, and also more likely not to have completed high school; but they are more likely than natives to have advanced degrees. All these demographic differences are consistent with immigrant-native differences shown in more familiar data sources, including the U.S. Census of Population . These demographic differences make it essential that, in testing the theory and pointing out immigrant-native differences in the incidence and conditional amounts of assimilating activities, we account for as many of them as possible. Since the essential point of the theory is that the central characteristic, immigrant status, will have opposite effects on the incidence and intensity of activities on the randomly chosen diary day, one's initial instinct of estimating a tobit model on these time-use data would lead one astray. Instead, the theory suggests using a double-hurdle model, of the type proposed by Cragg , which involves the joint estimation of a probit on the incidence and a truncated regression on the intensity. We can test whether the impact of immigrant status on these two outcomes differs by constraining its effects to be the same and testing the constraint using the normal distribution.8 The top half of Table 2 shows the determinants of the incidence of the particular assimilating activities, and the aggregate of the three assimilating activities, based on probits estimated over the entire sample.9 This table and all subsequent tables that show results describing incidence list the effects of a one-unit increase in the independent variable on the probability of the activity being undertaken. Before examining the predictions of the theory about incidence, consider the impacts of the control variables . 1) Men are more likely than women to engage in the activities that we believe may be assimilating, but only because they are much more likely than women to be working for pay; 2) Those with young children are less likely to engage in these activities, both because they are less likely to work and because they are less likely to be engaged in an educational activity; 3) As has been shown for a number of countries , there is a steady increase in the probability of engaging in each of these activities with greater educational attainment. Participation in assimilating activities overall is statistically significantly lower among immigrants, with a difference between them and natives of 1.5 percentage points . This central result is driven by purchasing activities, which are far less likely to be undertaken on the single diary day provided by the ATUS by immigrants than by natives. 10 Educational activities are more likely to be undertaken by immigrants , while rates of market work are essentially identical between the two groups. Overall the results for the crucial variable, immigrant status, do suggest weakly that the theory describes short-run immigrant-native differences in these activities. The bottom half of Table 2 tests the second major prediction, that, conditional on engaging in an activity on a given day, immigrants will spend more time on it. The sample sizes in these truncated regressions vary from activity to activity because the number of participants varies across activities. As with the discussion of incidence, we first examine the impacts of demographic differences . 1) African-Americans spend conditionally less time in the activities that may be assimilating, mainly because they spend less time in educational activities; 2) Men are more likely to spend time in these activities, entirely because, conditional on working for pay, they spend more time in the market; 3) Similarly, having more and especially younger children in the household reduces the amount of time in assimilating activities among those who participate in them; 4) Finally, the conditional amount of time in these activities rises steadily with educational attainment. Conditional on participating in the activity on the diary day, immigrants spend more time on it in each of the three categories. The extra time immigrants spend in what we have designated as assimilating activities is not small: 10.9 percent extra in purchasing, 9.7 percent extra in education, 4.0 percent extra in market work, and 5.7 percent extra in assimilating activities in total . 11 For each activity the final row of Table 2 provides the normal deviate testing the crossequation constraint that the effects of immigrant status on incidence and intensity are the same . 12 In each case the hypothesis of equality is strongly rejected. In its predictions about the allocation of time conditional on choosing to undertake a particular sub-aggregate of activities, time use in these activities is described fairly well by the theory. The data reject the notion that immigrant-native differences in the incidence and intensity of these activities are the same and, indeed, suggest the effects are in opposite and expected directions. 13 These results are only suggestive: Perhaps immigrant-native differences in incidence and intensity in the other seven activities on the diary day are also respectively negative and positive, and statistically different from each other. To examine this possibility, Table 3 presents estimates of probits and truncated regressions for the impact of immigrant status in each of these activities. The final column of the table presents these estimates for the intensity in the aggregate of these seven activities, which we designate as "non-10 This result is driven by purchasing of goods , which accounts for slightly more than half of total time in this category. Immigrant-native differences in travel time, which are arguably less likely to be assimilating, are much smaller. 11 Although we cannot know the nativity status of an ATUS respondent's fellow workers, it might be that those who are in blue-collar positions are more exposed to the native culture than other workers. Dividing the sample by this criterion, we do find that, conditional on positive work time on the diary day, and holding all the controls constant, blue-collar immigrants do work longer than blue-collar natives. 12 A problem might arise with this method if those who engage in the activity on a particular day are non-randomly selected from the sub-sample that ever engages in the activity. Only a tiny fraction of people are likely to engage in educational activities during a year, and nearly everyone does some purchasing; but only part of the sample works during the year. To examine this concern we re-estimate the models for work in Table 2 including only those respondents who stated that they usually have positive work hours in a week. The results, particularly the immigrant-native differences, are essentially the same as those presented in the Table. 13 The results look very similar when we re-estimate all equations separately for individuals younger or older than 40 years of age. The impact of immigrant status is nearly identical regardless of the age of the individual. assimilating," . In six of the seven aggregates, immigrants either have both greater or lesser intensities and incidence than natives, or one of the two effects is not significantly nonzero. Only for household activities are the differences in incidence and intensity between immigrants and natives negative and positive, and statistically different, as they were for assimilating activities. One might be concerned that some of the "controls" are endogenous-that choices about time use affect some of the variables that we have identified as demographic, particularly marital status, age and number of children, and perhaps educational attainment. To examine this, we re-estimated the models holding constant only the age, gender and racial/ethnic variables, with results nearly identical to those presented in Tables 2 and3. Another possibility is that the results differ by gender in more subtle ways than is captured by inclusion of an indicator variable. Separate estimates show that immigrant-native differences in intensity and incidence are almost identical for both men and women. 14 A possibly more serious problem is that immigrant status is endogenous-people choose to emigrate to the U.S. based on economic incentives . This means that our results do not reflect what would be observed if one could randomly choose members of the immigrant population. If, however, potential immigrants are rational, those who did migrate are those who expected and found the costs of assimilation to be less than those facing the average potential migrant. This would be true whatever the immigrant's position in the earnings distributions of the home and receiving countries. That being the case, our results underestimate the immigrantnative differences that we would observe if actual immigrants were randomly selected from the set of potential immigrants. Overall the findings accord fairly well with our theory of short-run immigrant-native differences in time use. Immigrants are less likely to engage in activities we have denoted as "assimilating," on a randomly chosen day, but conditional on doing so they spend more time on them than natives. No doubt other explanations are possible, but the findings are consistent with a theory of short-run fixed daily costs of assimilation. --- The Sources of Differences in Time Use Here we explore some possible sources of the fixed costs that underlay the results in Section 4. One obvious suspect is language knowledge, as there is substantial evidence that knowledge of English, or at least the opportunity to learn English, affects such outcomes as immigrantnative differences in wages. Accordingly, we focus much of our attention on various measures of English-language facility . The first measure that we use reflects the extent to which an immigrant has had time to acculturate him/herself generally to the U.S., namely the number of years since immigration. To create usefully sized cells we divide years since migration into the categories: Less than 6 years , 6-10 years , 11-20 years , and more than 20 years . A native whose parents are immigrants may also bear substantial costs of assimilating, although for many outcomes second-generation Americans 14 Another possibility is that immigrant-native differences differ by marital status, but that possibility too is not apparent in the data. Nor do the differences result from immigrants' much greater concentration in metropolitan areas: When rural residents are deleted, the results are nearly the same as in Tables 2 and3, except that the immigrant-native differences in Table 2 are slightly more pronounced. look much more like higher-order generation natives than like immigrants . To examine this we define nativity variables for natives' parents, including whether both are immigrants, the father is foreign-born , or vice-versa. Nearly 10 percent of natives have at least one immigrant parent, with half of these being children of two immigrant parents and the other half split fairly evenly between children whose immigrant parent is their father or their mother. 15 In Table 4 we substitute the indicators of years since migration for immigrant status in the probits and in the truncated regressions. We also add the indicators describing secondgeneration Americans. Consider first the estimates of incidence. Except for education the probit derivatives are largest and most negative for the most recent immigrant arrivals. Moreover, the effects diminish steadily in absolute size with years since migration for the aggregate of assimilating activities . The results for the intensities of activities are less consistent with the notion of acculturation lowering these costs. Except for purchasing activities, where the conditional amounts undertaken decrease monotonically with years since migration, there are no obvious distinctions between immigrants classified by years in the U.S. More support is provided by the estimated impacts of second-generation status on the incidence and conditional amounts of assimilating activities. Second-generation Americans look nothing like immigrants. Indeed, if both parents were immigrants, the respondent is more likely than other natives to engage in the activities that we have classified as assimilating, although the conditional amounts they undertake do not differ from those of other natives who participate in those activities. At least in terms of short-run differences in time use, these results suggest that the process of assimilation is complete by the second generation. As noted, a central aspect of the cost of acculturation is that of acquiring the native language. First, adopting the categorization of Bleakley and Chin , we divide immigrant countries of origin into three mutually exclusive categories: 1) Those where English is the primary spoken language; 2) Those where English is not the primary spoken language but is designated as an official language; and 3) All others, where English is neither the primary spoken language nor an official language. Fully 76 percent of U.S. immigrants come from this third type of country, about one-eighth come from countries where English is an official language but not the primary spoken language , and another eighth of U.S. immigrants hail from English-speaking countries. A second measure of language facility is more direct but not exogenous to choices about assimilation: Whether the household's interview in the CPS was conducted in a foreign language , observed among one-third of immigrants. Given the sensitivity of some outcomes of assimilation to whether the immigrant is Mexican or not , we also include an indicator for the 21 percent of immigrants in the ATUS of Mexican origin. The upper half of Table 5 examines the impacts of the treatment of English in the immigrant's country of origin on the probability that s/he undertakes an assimilating activity and on the conditional amount undertaken. The estimates suggest that immigrants who come from English-speaking countries look less like other immigrants and more like natives in how they allocate time to the so-called assimilating activities. Patterns of time use are quite different, however, among those immigrants who come from countries where English is only an official language, and for the large majority of immigrants from countries where English is not an official language. These latter two groups show the predicted time use patterns relative to natives. The only surprise here is that, at least for the incidence of these activities, the negative effects are greater for those from English-official countries than those from non-English-speaking countries. An alternative approach relies on the language in which the interview was conducted and includes the additional indicator for Mexican immigrants. The results, presented in the bottom half of Table 5, show that, conditional on their language ability, Mexican immigrants are no more likely than immigrants generally to undertake a particular assimilating activity; and conditional on that they do not perform any less of it. Weak English, however, does matter: Those immigrants whose CPS interview was not conducted in English are especially less likely to engage in assimilating activities; but conditional on doing so, they spend more time at those activities . These results underscore again the role of language knowledge in lowering the fixed daily costs of assimilation. 16 While language facility, or the possibility of it, appears to be a good proxy for the fixed costs in our model, there are others. One argument is that, independent of language ability, the fixed costs of participating in assimilating activities in the United States are higher for emigrants from less developed countries with economies that are more different from the U.S. economy: "How could this man, so recently removed from an altogether different life, explain to himself the product system in which he was enmeshed?" As a proxy for this idea we obtained the recent per-capita real GDP in the home country of each immigrant. 17 The average GDP per capita in the immigrants' home countries in 2008 was $10,355 , with a range from $230 to $94,354. Adding this additional proxy for the costs of assimilating to the equations in Table 5 produces the estimates shown in Table 6. The inclusion of this index of development changes the estimates of the effect of emigrating from an English-speaking country, since these are highly correlated, weakening the negative impact of the latter on the incidence and intensity of these activities. The effects of GDP per capita itself are consistent with our interpreting them as reflecting lower costs of assimilation: Immigrants from countries with higher GDP are more likely than other immigrants to undertake assimilating activities on a given day and spend significantly less time engaging in these activities, conditional on undertaking them. 18 16 The conclusions do not change if we interact the proxies for English-language knowledge with the individual's educational attainment. Nor do they change if we restrict the sample to Hispanics. Re-estimating the equations in Tables 2, 3 and 5 including only the sample of Hispanics, both natives and immigrants, we find that immigrants as a group have a lower incidence of these activities than natives. Conditional on engaging in them, however, the intensity is greater. Moreover, the immigrant-native differences are entirely due to differences in language knowledge. 17 For most of the countries of origin we use data for 2008 from the World Development Indicators of the World Bank. For a few others for which these were unavailable in that database, we obtained the information from the World Economic Outlook database of the IMF. GDP is converted to U.S. dollars using the exchange rate against the dollar. 18 Adding interactions of home-country GDP with the language categorizations adds nothing to these equations-the effects are apparently independent. We also experimented with other proxies for cultural differences, including dominant Christian-religion or Asian. These are so highly collinear with the variables English-language background and home-country GDP per capita that we cannot draw inferences about their possible independent effects. Another broad, but fairly weak proxy for these explanations is the extent to which other immigrants are prevalent in the area where the immigrant resides. This might lower the dayto-day costs of undertaking what we have denoted as assimilating activities. Restricting the sample to metropolitan residents, we link the data to Census 2000 information on the fraction immigrant in the metro area. 19 Adding this measure to the estimates in Table 2 does not alter the conclusions that immigrants are less likely to engage in assimilating activities but that the conditional means of their time inputs into them exceed those of natives. Either the size of the ethnic enclave does not matter, or our proxy for it is too weak to capture this possible effect. --- A Replication for Australia The theory presented above is general, so it should be applicable beyond the parochial confines of the United States. Australia is one of the few countries with large numbers of immigrants and large-scale time-diary data sets. The Australian Time Use Survey of 1992 included diaries completed by nearly all of the almost 7000 individuals ages 15 or over in the sampled households. The diaries were recorded in five-minute intervals on two consecutive days, with the days evenly distributed over the week. To make the analyses as similar to those for the U.S. as possible, we created control variables identical to those included in the tables above: marital status, gender, a quadratic in age, number of children and indicators of their age distribution, and educational attainment. 20 The data set also includes an indicator of whether the respondent speaks a foreign language at home, which we use to examine the sources of immigrant-native differences. The survey recorded activities in 280 different categories. To make the test as similar to that for the U.S. as possible, we aggregated these into the same ten sets of activities. Each of these aggregates includes travel time pursuant to the basic activity. The basic activities included in purchasing and market work are very similar to those in the ATUS. Most of the others are too, although education/training activities encompass a somewhat different set of basic uses of time. Immigrants account for 24 percent of the diary-days of the respondents in these data, compared to 23 percent for all Australians counted in the 1991 Census of Population and Housing. 21 Except for market work, the average amounts of time spent in the activities that we have shown might be viewed as assimilating look strikingly similar to the figures in 1. What we have classified as purchasing activities are more frequent in these data, but market work is less frequent. Among immigrants, 35 percent of the respondents state that they speak a foreign language at home, nearly identical to the fraction of immigrants in the ATUS with whom the interview was conducted in a foreign language. 19 We thank Brian Duncan for having supplied his tabulations from the Census 2000. 20 We exclude the few respondents over age 85 and thus outside the age range reported in the ATUS. Also, household residents in the Australian data are recorded as children only if they are under age 15, and their categorization by age differs slightly from that in the ATUS. Finally, the categories of educational attainment necessarily differ from those in the United States. We include as loweducated respondents those with secondary or lesser qualifications; as middle-educated those with trade qualifications or a certificate or diploma; and as high-educated those with a bachelor's degree or higher. We dropped the 5 percent of respondents who were still attending school. 21 http://www.ausstats.abs.gov.au/ausstats/free.nsf/0/4C64DE2D65803F30CA2574BF00167A44/$File/ 28210_1991_230_Australia_in_Profile.pdf Table 1.1. The results for the three activities are presented in Table 7, a replication of Table 2. Each probit is based on the entire sample of 12,998 diary-days for which all the data were available, and each truncated regression is based on all the individuals who engaged in the activity. The standard errors of the estimated coefficients account for clustering of the observations. 22 For each of the activities, the first column includes only the indicator for immigrant status, while the second adds the foreign-language indicator. All the estimated equations also contain the control variables discussed above. The results are qualitatively identical to those for the United States. As in the U.S., the conditional amounts of time spent in the assimilating activities on the diary day are greater among immigrants than natives. Also the probability of engaging in education/training on a given day is higher among immigrants, and the probability of purchasing or doing market work is lower. Although some of the estimated parameters are statistically significant, significance is lower than in the U.S. . Even the ability of the models to fit the data is similar to what we saw in Table 2. Finally, as in the U.S. data, tests of the equality of the immigrant effects on incidence and intensity reject the hypotheses for purchasing and for educational activities, although not quite for work. The role of language in generating the outcomes is striking. All of the effects for immigrants are mediated through language knowledge. Only those immigrants who do not speak English at home engage in conditionally more of the assimilating activities than do natives on the diary day. Englishspeaking immigrants are no different from natives in the likelihood of engaging in these activities, while non-English speaking immigrants are significantly less likely to be purchasing or engaging in market work, but significantly more likely to be undertaking education/training. As with the basic results, the results on the importance of language corroborate the findings for the U.S. An additional check is provided by the estimates of the probits and truncated regressions for the other seven categories of activities, presented in Table 8. For none of these seven do we reject the hypothesis of equal effects of immigrant status on incidence and intensity and also observe a negative effect on incidence and a positive effect on intensity with t-statistics above one. These results thus differ from what we observed for both purchasing and market work in Table 7 and look very much like what we saw in Table 3 for their American analogs. --- Conclusions and Implications for Heterogeneity Motivated by the immigrant-native differences in time use that we document here, we have derived a theory of the process of assimilation based on the notion that it is costly to assimilate. The cost is a barrier to assimilation. Some potential immigrants will not even emigrate, perceiving the barrier to be too great. Others will emigrate, but will not cross that barrier and undertake the activities that natives do, or at least not do so as often. Those immigrants who do cross the barrier have an incentive to undertake more of the assimilating activities on a given day than do natives. Identifying a number of activities viewed as leading to assimilation, particularly education, shopping, and market work, we use the 2004-2008 American Time Use Survey to examine 22 Among those who engaged in the same assimilating activity on both diary days, the within-person correlations of the residuals are 0.21, 0.30 and 0.32 for purchasing, education/training and work respectively. these predictions. They are strongly supported by the data, and immigrant-native differences in other activities are not characterized by the same lower daily incidence and higher conditional intensity as these activities. While immigrants no doubt are as likely as natives to engage in most of what we have denoted as assimilating activities over the long term, their engagement is more lumpy: In the short run they are less likely to undertake the activity but perform more of it if they do it at all. This is consistent with the role of fixed daily costs in affecting behavior. We also examine the sources of these apparent daily fixed costs of assimilation. Various proxies for them, including the immigrant's language background, suggest that language knowledge partly underlies the costs of assimilation. Higher GDP per capita in the home country also leads immigrants to behave less differently from natives, suggesting that unfamiliarity with American-style economic life also underlies those costs. We also tested the theory on Australian data from 1992, which have the advantage of coming from a country that is nearly twice as immigrant-intensive as the U.S. While the survey instrument defines activities slightly differently from the U.S. data, the Australian results look very similar to those for the U.S. In both countries, language plays an important role in time use assimilation by immigrants. Our view of the process of assimilation and the demonstration of its validity with time-use data suggest a testable implication for the commonly-examined outcomes of the assimilation process. Some immigrants will assimilate well, while others will not-our short-run results would extend to the long run for some immigrants. While much of the research on assimilation outcomes has focused on the time path of average immigrant-native differences, the heterogeneity implied here suggests that the cross-section variance of immigrants' earnings and hours will exceed that of natives. This should be true for immigrants as a group, but also for immigrants who are otherwise observably the same as natives, since unobservable factors will leave some residual heterogeneity. The same implications could be tested on such outcomes as wages/earnings, labor-force participation, and hours of work. In terms of policy, the results suggest a critical need to encourage immigrants to undertake assimilating activities-to overcome the short-run costs of assimilation. As we have shown, these costs involve familiarity with language and economy, and no doubt other aspects of life as well. Requirements of and subsidized immersion into the language and culture, perhaps like the Israeli ulpanim, are one possibility.23 Impacts of immigrant status and English-language knowledge home-country on the probability and conditional amount of an activity, Australian Time Use Survey, 1992 a a Includes all the controls in Table 7. --- Purchasing --- Supplementary Material Refer to Web version on PubMed Central for supplementary material. --- Appendix

Sharp differences in time use by nativity emerge when activities are distinguished by incidence and intensity in recent U.S. data. A model with daily fixed costs for assimilating activities predicts immigrants are less likely than natives to undertake such activities on a given day; but those who do will spend relatively more time on them. Activities such as purchasing, education, and market work conform to the model. Other results suggest that fixed costs for assimilating activities are higher for immigrants with poor English proficiency or who originate in less developed countries. An analysis of comparable Australian data yields similar results.

INTRODUCTION Ecological theory suggests that human development involves progressive and mutual accommodation between an active, growing human being and the changing properties of the environment in which the developing individual lives . As such, the specific contexts or environments in which children are raised influence their concurrent outcomes as well as their subsequent development. Parents with different cultural values could be assumed to have different parental values and parenting practices. In this perspective, examining parental values and behaviors requires one to be cognizant of how environmental factors, such as culture, impact and provide a source of parents' child-rearing ideologies and parenting goals and practices. According to O'Hagan , culture is the distinctive way of life of the group, race, class, community, or nation to which the individual belongs. It is the product of the values and perceptions that constitute the individual's knowledge and understanding of the world. According to the value theory that was proposed by Schwartz, values could be used to characterize cultural groups, societies, and individuals and to explain the motivation of human behaviors . Values are beliefs linked to affect; it could refer to desirable goals, could serve as standards or criteria and ordered by importance. More importantly, values could guide human actions. So cultural values shape an individual's perspectives of the world and permeate every aspect of daily life. As such, cultural values can affect individuals directly by establishing cultural expectations regarding people's dress, their customs, their patterns of work, religious ceremonies, and leisure pursuits . Indirectly, cultural values provide norms or expectations for such things as education and childrearing. An increasingly common way to conceptualize cultural value is to focus on the constructs of collectivism and individualism from the 1980s . Individualism refers to the extent to which individuals consider themselves as independent from others in their social or cultural group. Individuals who hold more individualistic cultural values are said to be motivated by their own preferences, goals, and benefits . Alternatively, collectivism is defined as the extent to which individuals consider themselves as being related to or connected with others with such individuals expressly motivated by the norms and values of their cultural or social group . Individuals who prioritize more collectivistic cultural values are said to be motivated by the norms and values of their social or cultural group . Dichotomy of individualism/collectivism is one of the most useful and widely researched constructs for understanding cultural variation in parents' beliefs and practices . Conceptually, individualism and collectivism map globally to Eastern and Western cultures, which differ in terms of history, values, and beliefs. American culture has been described as traditionally individualistic, in that it conceives the individual as an independent and autonomous entity comprising a unique configuration of internal attributes and behaves primarily as a consequence of those internal attributes . Conversely, many Eastern cultures, particularly Asian countries, such as China, are described as having a collectivistic cultural value. These individuals are said to be interdependent in that they emphasize the fundamental connections of human beings to one another. Whereas EA parents often see the need to encourage their child to be independent and unique, Chinese parents are more likely to encourage children to view themselves as part of the integrated whole of their family, community, and society, and not to emphasize their differences from others . As such, American children may learn to see the world strictly on an individual basis, whereas Chinese children may learn to see the world as a network of relationships. Although dichotomization of cultural values is a useful conceptual framework for understanding parental values, goals, and practices, researchers suggest that caution should be taken when considering similarities and differences between parents from different cultures . This caution arises from the fact that cultures are not homogeneous entities without individual variation . It would not be appropriate, for example, to assume that individualistic cultures lack a concept of relatedness and that collectivistic cultures fail to recognize the concept of individual choice. The relation between collectivistic and individualistic cultural values has been highlighted by Oyserman et al. . In their meta-analysis of 50 existing individualism and collectivism studies, Oyserman et al. found that individualism and collectivism are not opposing constructs. Rather, they appear to be statistically independent or orthogonal in nature. Hence, an individual doesn't necessarily have to be low in one dimension in order to be high in the other. Their findings also demonstrate that individuals in some cultures that have traditionally been considered to be primarily collectivistic or individualistic may in actuality be less so. Given the results of their meta-analysis, it is important to consider individualism and collectivism to be multifaceted dimensions that may coexist within a given culture. As such, they may be useful in describing differences and similarities among ethnic groups as well as providing a meaningful way to tie parenting beliefs and practices to a larger cultural context. One of the most important tasks of parenting is to help children achieve competence in a specific cultural context . During the last decade, cross-cultural parenting research has reflected an increasing awareness and recognition that much of parental cognition and practices are culturally organized . In particular, several researchers have investigated cultural differences in parental values, goals, and practices . These studies suggest that parental social cognitions and practices need to be understood and studied within the cultural contexts in which they occur. For example, parental values can be defined as ideologies that are statements of truth from the parents' point of view and they encompass parents' cognitions and beliefs about raising children and being a parent . In a previous study, Asian-American parents were reported to place a heavy emphasis on the importance of achievement in childhood . Such views are most likely a reflection of parents' cultural values and are important when considering the impact that parenting beliefs and goals have on children's developmental outcomes. Parental goals refer to the specific characteristics or traits that parents try to encourage or discourage in their children through specific childrearing interactions. Cultural values are tied to parents' conceptualization of parenting goals. According to Levine , the ways in which parenting goals are operationalized depend on the family's social, cultural, and economic context. For example, Miller et al. concluded that for American parents, self-esteem is a central goal of parenting, while Chinese parents have higher expectations for their children's educational attainments . In addition, Gorman also suggest that immigrant Chinese mothers characterize their parenting goals in relation to their cultural values, such as being self-sufficient, fulfilling one's obligations, respecting elders, and caring for others. Parenting practices have been defined as a wide range of ways that parents elicit, inhibit, influence, or otherwise control their children's behavior during day-to-day interactions. They are more specific ways that parents address their values and achieve their goals . The majority of research on parenting practices has almost exclusively focused on parenting style in both Chinese and American contexts. In the Western context, research on the dimensions of warmth and control has yielded a comprehensive model of four types of parenting styles: authoritarian, authoritative, indulgent, and indifferentuninvolved . Chinese parents were found to be more authoritarian than American parents ). Chao also suggested that understanding how Chinese parents' "train" their children puts into doubt the conceptual usefulness of parental demand and responsiveness for studying Chinese populations. Training can be defined as "a continuous monitoring and guidance of children" . She suggests that training is an essential Chinese parent form of nurturing. The nurturing aspect of training is reflected in parental involvement and support, but it does not include overt demonstrations of the parents' affection for the child, which are often emphasized by Western cultures. Studying parents' cultural values is useful because it provides us with an orienting tool for understanding the development and organization of parents' social cognitions and parenting behaviors. For example, in terms of parental goals, Chinese American and Taiwan Chinese parents were found to rate collectivistic parental goals more important than European American parents. In particular, Chinese parents rated persistence, politeness, concentration, and precision as more valuable than did European American mothers . In addition, recently Cheah et al. found the differences in Chinese immigrant and European-American mothers' expressions of warmth toward their preschool children. They found that Chinese immigrant mothers expressed less warmth than European-American mothers. Cultural differences were also found to interpret these different parental behaviors. European American mothers focused on more direct and outward demonstrations of warmth based on Western cultural values. Moreover, Chen et al. also found that cultural values were highly related to parents' self-reported expressivity. Eastern cultural values were generally associated with less emotional expression in the family. Hence, according to previous studies, it is concluded that European American parents who emphasized a more individualistic values reported different parental goals and practices from parents who emphasized more collectivistic cultural values. To date, however, although many cross-cultural studies have focused on examining ethnic differences on parenting values, goals, and practices, most of them fail to directly assess parents' endorsement of cultural values. Rather, many of these studies examine parental cognitions and practices and then, upon finding differences in parental values or practices across different ethnic groups, use culture as a post hoc explanation for why parents differ. Two problems exist with this approach. First, researchers may overgeneralize the effect that cultural values have on parental cognitions and practices. Falling back on culture as an explanation for differences may in actuality inflate differences between groups. Second, approaches that compare parents from different cultures and then explain findings by making summary statements about cultural values may limit our understanding of culture and parenting processes. Essentially, they may ignore the fact that as much variation exists within cultures as between . As such, instead of only conducting intercultural comparisons between Western and Eastern parenting, intracultural comparisons should also be considered as valuable methods to reveal variation in parenting processes within one cultural context. The current study would discuss the multifaceted nature of collectivistic and individualistic values that can coexist in one culture. Therefore, the first goal of the present study was to examine ethnic differences in collectivistic and individualistic cultural values, child-rearing ideologies, parenting goals, and parenting practices between mothers from the western United States and Shanghai/China. We hypothesized that mothers from Shanghai/China would highly endorse collectivistic cultural values, collectivistic parenting goals, and child-rearing ideologies about training while mothers from the western United States would have higher scores in individualistic cultural values, individualistic parenting goals, and practices in nurturance. In addition, child gender has been considered as a peripheral variable in studies of parental values, goals, and practices . For example, mothers of boys reported different parental attributions of young children's social behaviors from mothers of girls . A recent study also argued that gendered socialization is rarely founded as statistically significant in broad parenting style and parenting practices, and it could be an implicit variable so that parents could offer different products and responding to children differently according to children's gender . Given that, gender effect and interaction effect between gender and ethnicity would also be hypothesized. The second purpose of the study was to investigate relationships among cultural values and parenting for mothers from the western United States and Shanghai/China, respectively. Pearson product-moment correlations would be performed to explore difference patterns of correlations for two groups of mothers. We hypothesized that significant correlations among cultural values and parenting for each ethnical group of mothers would be hypothesized. The third purpose of the study was to examine the effects of cultural values on parental values and goals and practices for each group of mothers, respectively. We hypothesized that mothers' cultural values that mothers endorsed would predict their parental values and goals. We also expected that for both ethnic groups of mothers, cultural values would interfere with parenting practices and their parental values and goals would also contribute to the variance of parenting practices. --- MATERIALS AND METHODS --- --- Measures Three sets of questionnaires were employed to measure mothers' cultural values, child-rearing ideologies and goals, and parental practices. --- Cultural Values The Individualism/Collectivism Scale . In this study, the reliabilities of the scales for European American and the Mainland Chinese sample may not as good as previous studies but were acceptable. --- Parental Values and Goals Mothers' parental values were assessed by Child-Rearing Ideologies Questionnaire . This 13-item scale covered two areas, "ideologies on child development and learning" and "ideologies of the mother-child relationship" . Respondents need to indicate the degree to which they agree or disagree with each item on a seven-point scale, from 1 = strongly disagree to 7 = strongly agree. Sample items from the ideologies of child development and learning subscale are "Children are by nature born innocent, " "Mothers must begin training child as soon as ready, " and "Children can improve in almost anything if they work hard." Sample items from the ideologies of the mother-child relationship subscale are "mothers primarily express love by helping child succeed, especially, in school" and "a child should be in the constant care of their mothers or family." Cross-cultural studies of parenting measured parental values by CRIQ for Taiwan Chinese and Chinese American parents and reported acceptable internal consistency levels for these ethnicity groups . Few studies explored European American parents' parental values by using this method. Jose et al. reported total scores of two subscales and found that CRIQ yield unacceptable internal consistency but acceptable test-retest reliability for European American parents of young children . However, as this is the most appropriate scale measuring parental values relating to collectivistic and individualistic cultural values, same scoring methods were used for the current study. The internal consistency level of the current study for both European American and Mainland Chinese mothers are also acceptable. The Importance of Collectivist and Individualist Traits in Child Scale was used to assess mothers' parenting goals concerning their child's desired personality traits. In response to the question "How important do you think it is to encourage the following personality traits in your child?" parents rated 5 individualist traits and 7 collectivist traits by a seven-point scale . Parents received an average score for the two clusters separately, a high score for a cluster indicated that the parent highly endorses that particular cultural value for their child. According to previous research focusing on European American parents and Chinese American parents, the internal consistencies of these two subscales are acceptable . In this study, the reliabilities of both individualistic traits and collectivistic traits for European American and Mainland Chinese sample were also acceptable . --- Parenting Practices The Parenting Dimensions Inventory Short Version was used to assess mothers' parenting practices. The PDI-S has been used in research on immigrant Chinese parents and was translated into Chinese by Kelly and Tseng . In previous research conducted with immigrant Chinese and European American mothers, Sebire et al. reported Cronbach's alphas of 0.87 and 0.76, respectively. The first section of this scale was utilized for the present study. It was a 13-item 6-point Likert-type scale assessing parenting nurturance , inconsistency , and discipline . A sample item for nurturance could be "I encourage my child to talk about his or her troubles." However, Cronbach's alphas of inconsistency and discipline subscales were not acceptable for both ethnic groups. So only nurturance subscale was used in further analysis. --- Procedures The Institutional Review Board at Washington State University first approved this research project to collect data from parents of 4-6 years old children in both the United States and Mainland China. After that, mothers from the western United States and Shanghai/China were recruited from local preschool and kindergarten programs. Principals and program directors were contacted initially in person, and the protocol was explained to principals by the researchers in some depth. A letter inviting mothers to participate and a consent form were distributed through children's preschool or kindergarten programs. Mothers who agreed to participate in this study signed the consent form, completed a questionnaire packet, and returned these to their child's preschool or kindergarten teacher. Both groups of mothers were asked to respond to questions regarding their cultural values, parenting beliefs, and parenting practices. After completed questionnaires were obtained, mothers were sent a thank-you letter and a small gift. The majority of questionnaires were initially developed in English. Mothers in Washington were distributed questionnaires in English while mothers in Shanghai were given questionnaires that had been translated into Chinese. Some questionnaires were previously translated into Chinese by other researchers, such as ICITCS and PDI. For questionnaires that have not been previously translated into Chinese, such as the Individualism/Collectivism Scale , a forward and then back translation method were utilized. In this method, the researcher translated the questionnaires into Chinese and a native Chinese speaker back-translated the questionnaires into English. This method of forward and back translation has been shown to be an acceptable method for ensuring that questionnaires are translated correctly across languages . --- ETHICAL STATEMENT This study was approved by the Research Ethics Committee of Washington State University, Washington. All participants involved in our study were given written, informed consent forms, which were signed by each participant and their guardians and returned to us. The ethics committee approved this consent procedure. --- RESULTS --- Ethnicity Differences in Cultural Values and Parenting To explore the differences in cultural values, parental social cognitions, and parental practices between two groups of mothers, MANOVA were performed. Ethnicity and children's gender served as independent variables while cultural values, parental social cognitions, and parental practices were served as dependent variables. Descriptive statistics of study variables and results of ethnicity differences are presented in Tables 2,3. Results indicated significant overall ethnicity differences between each group, F = 19.46, p < 0.001, η 2 = 0.41. No significant differences were found in children's gender or interaction effects between ethnicity [F = 1.12, p > 0.05, η 2 = 0.04] and children's gender [F = 0.91, p > 0.05, η 2 = 0.03]. Specifically, first, mothers from Shanghai/China reported themselves as both more collectivistic and individualistic than European American mothers. Second, mothers from Shanghai/China held beliefs about the importance of training and collectivistic goals more strongly than mothers from the western United States. In contrast, mothers from the western United States more strongly endorsed individualistic goals to be important for their child. No significant difference was found between European American and Mainland Chinese mothers in terms of their parenting practices, suggesting that Mainland Chinese mothers have similar practices in nurturance with European American mothers on average. --- Cultural Variations in Relationships Between Cultural Values and Parenting In order to examine how mothers' cultural values predict their child-rearing ideologies and goals, and how cultural values and parenting social cognitions predict their parenting practices, Pearson product-moment correlations were first calculated. Since results of multivariate analysis of variance indicated strong ethnicity differences between two ethnicity groups, correlation analysis was conducted separately for mothers from two different ethnicity groups to examine the pattern of relationships among the variables of interest. Second, a number of multiple regression analyses were performed separately for mothers from Shanghai/China and the western United States to further explore intergroup differences in predictions of parental cultural values on their parenting. --- Correlations Between Cultural Values and Parenting Results suggested a few similar and different patterns of associations between two ethnical groups . For example, both groups of mothers' cultural values were associated with parental ideologies in training and their individualistic and collectivistic parental goals were correlated. In terms of different patterns, first, Shanghai mothers' individualistic and collectivistic cultural values were moderately correlated while European American mothers' cultural values were not . Second, Shanghai mothers' cultural values were correlated with their parental goals, but only collectivistic cultural values were associated their parental ideologies. However, European American mothers' individualistic parental goals were not associated with their cultural values and parental ideologies. Third, Shanghai mothers' collectivistic cultural values , child-rearing ideologies , collectivistic parenting goals , and individualistic parenting goals are associated with their parenting practices. But European American mothers' cultural values and child-rearing ideologies are not correlated to their parenting practices. Only individualistic parenting goals are associated with their parenting practices . --- Interaction Effects of Ethnicity and Cultural Values In order to examine whether mothers' cultural values could predict their parental values and goals, and also predict their parenting practices, interaction effects between ethnicity and cultural values were examined in advance. Multiple hierarchical linear regression analyses have been conducted so that product term of ethnicity with each cultural value were entered as independent variables. Parental values, goals , and parenting practices served as dependent variables, respectively. For each hierarchical linear regression analysis, significant interaction effects between ethnicity and collectivistic cultural values were found on parental collectivistic goals , individualistic goals , parental values , and practices . No significant interaction effects were found for ethnicity and individualistic cultural values. Therefore, the effects of cultural values on parental values, goals, and practices were examined separately for each ethnicity group. --- Predictions of Shanghai Mothers' Cultural Values to Parenting According to the result of high correlation between collectivistic and individualistic cultural values for mothers from Shanghai/China, two hierarchical regression analyses were conducted to examine which cultural value was more likely to predict mothers' child-rearing ideologies and goals. In the first analysis, two blocks of independent variables were entered into the model as predictors of mothers' child-rearing ideologies. Collectivistic cultural values served as block one and both collectivistic and individualistic cultural values served as block two. As shown in Table 5, Shanghai mothers' collectivistic cultural values predicted mothers' child-rearing ideologies, F = 19.16, p < 0.001, and explained 17% of Mainland Chinese mothers' child-rearing ideologies in training. In block two, Shanghai mothers' individualistic cultural values did not predict their child-rearing ideologies. According to high correlation between individualistic and collectivistic parenting goals for mothers from Shanghai/China, a combined score of the two variables was used as dependent variables for the current hierarchical regression analysis. Again, two blocks of independent variables were entered into the equation as predictors of mothers' global parental goals . Collectivistic cultural values served as block one and both collectivistic and individualistic cultural values served as block two. The results revealed that Shanghai mothers' collectivistic cultural values predicted mothers' parenting goals, F = 13.49, p < 0.001, and explained 12% variance of the dependent variable . In block two, Shanghai mothers' individualistic cultural values did not predict their parental goals. A hierarchical regression analysis was conducted to examine the predictors of mothers' parenting practices . For this analysis, two blocks of independent variables were entered into the model as predictors of mothers' nurturing behaviors. Shanghai mothers' cultural values served as block one and mothers' parenting goals and ideologies served as predictors in block two . Results reveal that Shanghai mothers' cultural values could predict their parenting nurturance [F = 2.64, p < 0.05], specifically, collectivistic cultural values could significantly explain variance in parental practices . In block two as a whole model, Shanghai mothers' cultural values, goals, and ideologies could predict their parenting nurturance [F = 2.26, p < 0.05]; however, while mothers' cultural values were controlled, either parental goals or parental ideologies did not predict mothers' behaviors in nurturance, respectively. --- Predictions of European American Mothers' Cultural Values to Parenting In the first regression analysis, individualism and collectivism subscales served as independent variables while CRIQ served as the dependent variables. The results show that mother's cultural values could predict their ideologies in the importance of training their children, F = 18.69, p < 0.001, and explained 33% variance of parental ideologies, R 2 = 0.33. For European American mothers, endorsement of both individualistic and collectivistic cultural values predicted CRIQ scores . According to results of correlation analysis, European American mothers' cultural values were not associated with their individualistic parental goals, so only one regression analysis --- DISCUSSION AND CONCLUSION Ecological theory and previous research suggest that culture plays an important role in parenting processes . The findings from this study affirm this notion and suggest that parental beliefs and goals appear, to some extent, to be culturally organized. For example, as hypothesized, mothers from Shanghai/China and the western United States had different child-rearing ideologies and goals. Shanghai parents endorsed more collectivistic goals while European American parents endorsed more individualistic goals. Meanwhile, mothers from Shanghai/China had higher levels of Chinese traditional beliefs about training. However, the findings from this study are different from previous studies of parenting of Chinese and American parents 1 According to results of correlation analysis, European American mothers' cultural values and collectivistic parental goals were not associated with their nurturance, so regression analysis was not conducted for European American mothers. in some important ways. First, given that little previous research has measured parents' cultural values explicitly, in addition, little research has studied the cultural process of parenting with Mainland Chinese parents. The present study extended previous research on cross-culture and gained new insights into the cultural process of parenting, by examining the ethnicity differences among mothers' cultural values, parental social cognitions, and parenting practices in two contexts: Mainland Chinese and European American. Second, the results of the current study suggested that mothers from Shanghai/China were both more collectivistic and individualistic than mothers from the western United States, which is partly in contrast to that found in the previous research. Researchers have suggested that Chinese or Chinese immigrant individuals possess less of an individualistic orientation than European Americans. For example, in their examination of cultural values using a collectivistic and individualistic perspective, Oyserman et al. found that of the 20 countries sampled, Chinese and European American individuals looked the most different, with Chinese individuals reporting more collectivistic and less individualistic values. A recent study compared the East German region and Chinese region also found Chinese region tend to be more collectivist and less individualistic than East German . The Asian culture has stronger collectivism as compared to individualism, in such a traditional and conformist cultural context, mothers from Shanghai/China in the present study consistently showed a higher level of collectivism. Meanwhile, they also reported more individualistic. A considerable reason may be due to social change, as Schönpflug and Yan pointed out. In China, the individualistic value orientation has also developed to meet the demands of a modernized society. Especially, Chinese mothers in the present study were from the biggest and modern city, Shanghai. These individuals live in a very urban, modernized part of China, are well educated, and are considered to be from middle-class to upper-middle-class backgrounds. As such, these mothers have frequent opportunities to interact with the modern world and know Western cultural values and conceptions of parenting through their use of the internet, their educational opportunities, exposure to diverse foods, and opportunities to meet and associate personally with those of different cultures. As a result, these Shanghai mothers more highly endorsed individualistic as well as collectivistic cultural values. Given that this sample was based largely on individuals who were not parents, it is limited in its ability to generalize to the larger population. Second, results of the current study suggested that cultural values could be important predictors of parental ideologies and goals. However, these predictions reveal strong cultural roots of parenting issues in both ethnic groups. For example, only for Shanghai mothers, their collectivistic cultural values were related to their parental goals and ideologies beliefs, while for European American parents, their individualistic cultural values have no relationships with their individualistic goals and practices. Meanwhile, inconsistent with the hypotheses, the predictive effects of cultural values on parenting practices were not significant for European American and Shanghai mothers. Therefore, despite the fact that mothers from Shanghai/China were higher on both individualism and collectivism, when it came to which values were most important in predicting parental social cognitions, our results showed that Shanghai mothers' collectivistic values were more important. One explanation of this different prediction pattern for European American and Shanghai mothers could be their beliefs about important guidelines directing their parenting behaviors. Mothers from Shanghai/China believe Chinese traditional cultural values, which includes theories of education and parenting, such as the historical roots of Confucian sources . From this perspective, children are considered to be innocent, lacking in knowledge, and have innate goodness . One of the most widely identified characteristics of Confucian philosophies is the emphasis Chinese parents place on their children's acquisition of academic skills . For mothers from the western United States, their parenting goals were important contributions of their parenting behaviors. As such, their goals about self-esteem and creativity direct their behaviors of nurturance. Several limitations of the present study need to be noted. First, our sample was a convenience sample from the biggest city of China and rural area of the United States. As a result, our findings cannot be generalized to most Mainland Chinese parents. Second, only mothers completed self-reported questionnaires. Fathers' cultural values, parental social cognition, and parenting practices were missing. Literatures have reported different parenting styles, involvement, and practices between mothers and fathers . So, parents' gender could be an important impact factor to parenting processes. Third, our measures were self-reported questionnaires, which may yield unreliability problems. It also should be noted that findings from the study only indicated mothers' perception of their cultural values and parenting processes but not the "reality." Moreover, because of the methodology issues, it was not possible to make causal inference about relationships among parents' cultural values, parental social cognitions, and parenting practices. Future longitudinal or experimental studies are needed to explore causal relations among these parenting variables. Future studies can also incorporate acculturation experiences that can be measured by qualitative methods and explore how global process influence parenting processes. Despite these limitations, these results suggest that parents' cultural values are important contributors to parental beliefs and goals for their children. It makes sense that parents' endorsement of collectivistic values should positively relate to their collectivistic goals and beliefs in the importance of training. These results fit nicely with previous research on the connection between parents' beliefs and goals . In addition, the cultural roots of parenting revealed the complexities in the social dynamics worldwide. These conclusions can be used to support the positive parental cognitions and family functioning. --- DATA AVAILABILITY STATEMENT The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation. --- ETHICS STATEMENT This study was approved by the Research Ethics Committee of Washington State University, WA, United States. All participants involved in our study were given written, informed consent forms, which were signed by each participant and their guardians and returned to us. The ethics committee approved this consent procedure. --- --- 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.

Cultural values can be considered as important factors that impact parents' social cognitions and parenting practices. However, few studies compare specific cultural values of parents and the relationships between cultural values and parenting processes in eastern and western contexts. This study examined the ethnicity differences in mothers' cultural values, parental social cognitions (child-rearing ideologies and goals), and parenting practices between Mainland Chinese and European American contexts. Predictors of parenting goals and parenting practices were also investigated. Mothers of 4-6 years old children from the western United States (N = 78) and Shanghai/China (N = 96) participated in this study. The results suggested that mothers from Shanghai/China were both more collectivistic and individualistic than mothers from the western United States. Chinese mothers more strongly endorsed training and collectivistic parenting goals, while European American mothers more strongly endorsed individualistic parenting goals for their children. However, no significant difference was found in parenting practices for both groups of mothers. For both ethnic groups, in general, mothers' cultural values have small but significant impact on their parenting processes. The prediction of cultural values and parenting goals on parenting practices were also different for both ethnicity groups. Although Chinese mothers were higher on both individualism and collectivism, their collectivistic values were more important in predicting parental social cognitions.

Introduction Infertility affects one in five women in the USA, according to the CDC [1]. Studies have shown that infertility impacts women in a variety of significant ways; one such study found that women with infertility had a 32% increased relative risk of mortality of any cause than women without infertility [2]. With the exception of advancing age and increasing BMI, it was found that infertility rates were comparable across various races/ethnicities, educational backgrounds, and household income brackets [3][4][5]. However, the rates at which women seek treatment for infertility correlate with socioeconomic status, higher education, and whether or not they were insured [5]. Treatments for infertility have been collectively referred to as medically assisted reproduction , encompassing assisted reproductive technology , in vitro fertilization , and intrauterine insemination , among others [1]. Studies show that historically marginalized patients are less likely to seek treatment for infertility compared to their white counterparts [6]. Healthcare inequities research seeks to identify potential barriers to MAR access and is necessary to increase accessibility to successful treatment for future patients with infertility. Healthcare inequities are defined as systematic differences in access to healthcare between populations due to specific characteristics pertaining to each group [7]. Inequities in healthcare are often associated with demographic characteristics including gender, socioeconomic status, education level, geographic location, race, and ethnicity [7]. In general, research indicates that certain social inequities majorly influence the health, well-being, and quality of life of affected patients with infertility [8]. Within MAR research, many studies focus on health factors linked to infertility [9]. In conjunction with these existing studies, further research on healthcare inequities can help elucidate barriers to accessing care. To our knowledge, this scoping review was the first of its kind to investigate research into healthcare inequities for people seeking care for infertility. A scoping review design was chosen due to the ability of scoping reviews to compile large bodies of literature and subsequently identify knowledge gaps within that literature. This design is helpful in identifying specific research questions that may be further pursued by systematic reviews [10]. In this study, multiple databases were used to evaluate studies pertaining to MAR, specifically as it relates to healthcare inequities. The purpose of our study was to identify which areas of MAR research concerning healthcare inequities may be inadequate, so that more targeted research in those areas can be pursued in the future. --- Methods We conducted a scoping review to identify the state of inequities research related to MAR and to determine where gaps exist. We conducted our study in accordance with best practice recommendations according to the Joanna Briggs Institute methodology for scoping reviews [11]. For standardization of reporting, we adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping Reviews [12]. We used a pilot-tested methodology incorporating standardized search strategies, inclusion/exclusion criteria, and data extraction materials. Our entire methodology and protocol were uploaded to Open Science Framework to ensure transparency and reproducibility of results [13]. This study did not constitute human subject research and was not subject to Institutional Review Board oversight. --- Literature Search In July 2022, we performed a database search of MEDLINE and Ovid Embase databases to identify published articles on health inequities related to MAR. According to the JBI Manual, two online databases should be used to search for articles pertaining to the review topic [11]. A 2016 study showed that use of these two specific databases together retrieved over 97% of citations included within 120 systematic reviews [14]. Published articles pertaining to inequities within the topic of MAR were obtained using PubMed's and Embase's list of vocabulary. Search terms were created using the National Institute of Health's list of health inequity populations, which encompass the following: race and ethnicity, sex, gender, LGBTQ + identity, under-resourced/rural populations, education level, income, and occupational status [15]. Our search was modeled after a recent publication within the field of laryngology following guidance and recommendations from the JBI Manual [11,16]. This search was published a priori on OSF [13]. --- Research Question Our scoping review was focused on the following research question: Among patients needing MAR, what research has been published on inequities, and how has that research changed over the past six years ? We set out to answer sub-questions which included did studies investigating similar inequities in MAR have concordance of findings and to what extent has Sexual and Gender Minorities been researched since the NIH's 2016 addition? The purpose of our scoping review was to identify the state of research into inequities within MAR. Additionally, we sought to provide recommendations for future research. --- Training We used two different resources for training of investigators which were delivered in person and/or on video. Prior to conducting this study, all authors were trained on the purpose and methodology of conducting a scoping review according to the JBI Reviewers' Manual 2020 [11]. The Cochrane Learning Live webinar provided supplemental information on scoping reviews as well [17]. --- Selection Process After identifying citations from our systematic search, we uploaded our results into Rayyan, a platform used for conducting title and abstract screening [18,19]. Two authors first removed duplicates from the initial search and then conducted title and abstract screening according to inclusion criteria described below. The authors conducted screening in a masked, duplicate fashion. Conflicts in decisions between investigators were resolved through discussion, with a third investigator available for adjudication. Rationale for exclusion of studies was recorded and presented in the PRISMA flow diagram. --- Inclusion and Exclusion Criteria The population, concept, and context framework provided by the JBI manual was used to develop criteria for inclusion in this scoping review [11]. Our population included literature with one of the following study designs: cohort studies, retrospective database reviews, cross-sectional analyses, literature reviews, qualitative studies, scoping reviews, systematic reviews/meta-analyses, clinical trials, and case-control studies. The concept of our scoping review consisted of research focusing on health inequities related to MAR. To increase sample validity and feasibility, our review only included literature published in English [20,21]. The context was addressed by limiting our inequities to the NIH's list of health disparity populations [15]. Studies included in this analysis were published between 2016 and 2021. This restriction was based on the NIH's classification of Sexual and Gender Minorities as a health inequity population in 2016 [22]. Finally, we limited the scope of our review to publications with study populations from the United States due to inconsistent connotations regarding inequities across cultures [23]. Criteria for exclusion in our data analysis included studies which were published prior to 2016 or after 2021, were published in a non-English language, were unrelated to MAR, were related to fertility preservation , did not analyze one of the health inequities listed, non-human studies, and were published as a letter to the editor, correspondence, or commentary. These study designs were excluded as they do not consistently report original research. The PRISMA flow diagram shows the reasons for exclusion throughout the screening and data extraction process. --- Data Charting We used a pilot-tested Google Form to extract data from studies including title of the study, author name, PubMed Identifier, publication year, years analyzed, study design, number of subjects enrolled, and setting . Data points were based on recommendations from the JBI Reviewers' Manual 2020 [11]. As a calibration exercise, two researchers extracted data from five identical studies. Findings were then reconciled through discussion with a third author available to resolve disagreements as necessary. Following completion of this calibration exercise, the authors then completed extraction from the full sample obtained in the screening process. Full sample data extraction was completed in a similar fashion. Findings for each inequity were summarized in a table including the author name, publication year, setting, number of participants, conditions examined, inequities examined, and a brief summary of the findings from each study. --- Use of Language We used standard language based on the American Medical Association's Advancing Health Equity: A Guide to Language, Narrative and Concepts to provide equity-centered, person-first language [24]. If an included study did not adhere to this guide, efforts were made to standardize language without losing original author intent. The following race-conscious terms adopted from the AMA were used throughout this study: Black, white, Hispanic/Latina/Latino/Latinx, Native peoples/Indigenous peoples/American Indian and Alaska Native [24]. The term "historically marginalized" was used to refer to groups who have been oppressed, excluded, and segregated [24]. The AMA defines "sex" and "gender" as separate concepts. "Sex" refers to the assignment at birth as either a male or female "Gender" refers to the emotional, psychological, or social behaviors which define someone as a man, woman, both, or neither [24]. Studies which did not delineate between sex or gender were coded under both terms. We used the acronym LGBTQ + as a general term to describe all of the sexual orientations as well as sex and/or gender identities [24]. --- Data Summary and Presentation Our findings were summarized using Stata 17.0 . We described frequencies and percentages of which inequities were found, study designs , and settings of each study . The frequency of studies investigating research into Sexual and Gender Minorities since 2016 was also assessed. --- Results --- General Characteristics of Included Studies Our literature search initially yielded 5318 articles. After 917 articles were identified as duplicates and removed, the titles and abstracts of 4401 unique results were screened, with 96 included studies remaining. Among these, 30 studies did not meet inclusion criteria and were therefore excluded from data extraction. Sixty-six studies were included for full-text review and extraction. The PRISMA flow diagram-designated Fig. 1-demonstrates the study selection process and provides brief reasoning for exclusions. Table 1 outlines the frequencies of the inequities examined, study designs, and study settings. The most common inequity examined within our sample was race/ethnicity , followed by income status , and education . The least common inequities examined included sex and/or gender , occupational status , and rural/under-resourced populations . Table 2 summarizes the main findings of included studies with respect to inequities examined. Figure 2 demonstrates the frequencies of the top three most commonly examined inequities. --- Race/Ethnicity Within the included studies, 45 examined race/ethnicity. The majority of these examined negative outcomes following MAR such as in vitro fertilization, intrauterine insemination, and intracytoplasmic sperm injection, among others. Low live birth rates following MAR were found in Black [6,34,40,46,50,51,61,63,65,69,73,76,77,88,90], Asian [6,40,50,51,61,63,69,73,77], Hispanic [6,34,51,57], and Middle Eastern/North African women [75]. Low intrauterine/clinical pregnancy rates were seen in Black [6,51,65,69,85,88], Asian [6,51,65,69,85,88], Hispanic [6,51,69], and American Indian/Alaska Native [33] women. Two studies found high spontaneous abortion rates in Black women [6,73]. Low implantation rates were seen in both Asian [57] and Black [76] women. Humphries et al. found an association between increased risk of pregnancy loss and Hispanic, Black, and Asian race/ethnicity [51]. American Indian/Alaska Native women had low delivery rates [33]. Salem et al. found low fertilization rates after intracytoplasmic sperm injection in Middle Eastern/North African women [75]. One study found that BIPOC women undergoing ART were more likely to give birth to a low gestational age or extreme preterm infant [85]. Another study found that Black women using ART were more likely to have preterm or low birth weight infants [34]. In contrast, two studies found that race and ethnicity were not associated with blastocyst formation rate [56] or spontaneous abortion rates [88]. Six studies found that race and ethnicity were not associated with other aspects of infertility treatment, such as financial strain, duration of treatment, receiving medical evaluation, or having treatment declined [35,39,41,47,52,72]. In addition to investigating outcomes following MAR, the included studies evaluated the likelihood of seeking infertility treatment. Four studies found that ART use was highest in white women [27,28,43,73], while three studies found that Asian women had the highest rate of use [38,84,89]. Seven studies found that Hispanic women were less likely to seek out infertility treatments or use ART [6,35,38,45,54,83,84]. Some studies found Black women [6,26,38,54,83,84], Asian women [6,35], American Indian/Alaska Native women [38], or Pacific Islander women [38] to have lower rates of infertility treatments. Two studies found that Black women were more likely to discontinue IVF treatments [29,76]. --- Sex/Gender There were four studies that examined sex and/or gender findings in our sample. Rangel et al. found that female surgeons were more likely to use ART than male surgeons [74]. Although multiple health organizations recommend both individuals in a couple struggling with infertility be Quinn & Fujimoto, 2016 [73] Literature review --- Single institution Assisted reproductive technology Race/ethnicity, income, education Non-Hispanic white women with higher levels of education and household income were more likely to report using fertility services. Multiple studies have shown that Black women have lower live birth rates and higher spontaneous abortion rates after IVF, while Asian women were found to have lower cumulative birth rates. Some studies showed that the cost of one IVF cycle in the USA could exceed half of the average patient's annual disposable income. evaluated, Strasser and Dupree found that men were only evaluated a quarter of the time [80]. Private funding in the form of grants helped increase access to fertility care for single men and women [71]. In one study, participants supported limitations to IVF treatment due to age, disproportionately in favor of restricting access for women compared to men [91]. --- Income Of the included studies, 23 found that income was positively correlated with access to treatment and/or decreased financial strain [6, 25, 27, 30, 36, 39-42, 45, 47, 52, 54, 58, 64, 69, 70, 72, 73, 80-82, 89]. Two studies reported no correlation between income and limitations to treatment [29,78]. One study found that lower incomes were associated with lower live birth rates [46]. --- Rural/Under-resourced Regarding location, three studies found that living in rural areas created a barrier to accessing treatment [48,65,70]. One study found that those living in a metro area were less likely to have ethical concerns about infertility treatment and one study found no correlation to MAR being associated with geographical region [32,47]. --- Education In our sample, 22 studies examined education level and its varying associations to infertility treatment. Of the included studies, 14 found that higher levels of education were positively associated with receiving MAR treatment [27, 34, 38-40, 45, 54, 64, 69, 72, 73, 78, 81, 84]. Five studies showed inconsistent associations between higher levels of education and various MAR outcomes [32,42,47,68,91]. Three studies found no correlation between the level of education and MAR outcomes [46,52,86]. LGBTQ + Since the NIH's classification of Sexual and Gender Minorities as a health disparity population in 2016, 15 articles within our sample investigated LGBTQ + inequities in MAR, illustrated in Fig. 3. In regards to the findings of the studies, barriers to accessing MAR were common themes. Three studies found that fertility clinic websites were lacking in educational content focused on LGBTQ + fertility issues [31,53,55]. One study found that over half of fertility clinics partnered with the Society for Assisted Reproductive Technology displayed LGBTQ + content on their homepage; however, these clinics tended not to be found in the Midwestern or Southern United States [87]. Other barriers discussed in our studies were difficulties with insurance approval for treatment [30], negative experiences with treatment providers [31], and lack of benefits and discrimination [62]. In contrast, one study found that access to infertility treatment was increased for LGBTQ + patients through funding from charity foundations [71]. Regarding MAR outcomes, three studies found more positive outcomes for LGBTQ + patients compared to their heterosexual and cisgender counterparts [44,60,66]. Downing et al. found no differences in outcome risks between same-sex couples using ART and those not using ART [37]. Similarly, Nazem et al. found that pregnancy outcomes did not differ between same-sex and heterosexual couples [67]. One study by Arocho et to support age limitations on IVF use for women [91]. One study found that there was no association between sexuality and negative or positive MAR beliefs [86]. --- Occupational Status Of our included studies, five examined occupational status. Rangel et al. found that through both non-assisted conception and ART, female surgeons were more likely to have major pregnancy complications than non-surgeons [74]. Greil et al. found that women who were unemployed were less likely to undergo fertility testing; meanwhile, employed women undergoing MAR were more likely to have depression symptoms [45]. One study found that white patients were more likely to report that taking time off work would be a barrier to accessing MAR [52]. Lindheim et al. found that couples undergoing ART in the USA were less likely to take on extra employment in order to afford care [62]. One study found that occupational status was not associated with financial strain due to infertility treatment [39]. --- Discussion Our findings identified several limitations for patients who use or attempt to access MAR. Included studies in our sample frequently evaluated race/ethnicity, income, and education inequities and their association with MAR. However, research into MAR inequities, with respect to sex and/or gender and those in rural/under-resourced areas, are in need of ongoing investigation. We will further discuss the areas in which research is deficient and explore the significance of these gaps. Race/ethnicity is associated with significant inequities in infertility treatment. In our review, the majority of studies evaluated race and ethnicity. The gaps within this line of research are numerous and complex, and though our study has highlighted some, there are likely more that have yet to be researched. Additional research is greatly needed in many areas; however, only a few are described here. First, our review identified gaps in access to healthcare, and additional research is needed to determine the extent and nature of inequities in infertility treatment. A usable system for race and ethnicity documentation is critically necessary for standardization, in order to facilitate the conduct of essential studies. The Society for Assisted Reproductive Technology does not require practitioners to document race/ethnicity; thus, this data is missing for a substantial proportion of patients [92]. A 2021 study estimated that information regarding racial and ethnic demographics is missing for over 47% of patients within the SART database [93]. Turner et al. conducted an investigation of race/ethnicity reporting in clinical trials which found that only 44% of studies reported any race/ethnicity data over the twodecade study period [94]. They also found a lack of crosstabulation of race and ethnicity reporting, to better capture the diversity of these populations [94]. For example, Asian populations are difficult to properly study, owing to the complex heterogeneity of this group. Women from Asian backgrounds are often all grouped together within one category, which limits data analysis. However, placing Asian women into specific categories runs the risk of sample sizes too small for adequately powered or meaningful analyses [94]. More research is needed to evaluate the collection of patients' race/ethnicity information. Also, a majority of studies on inequities in infertility treatment focus solely on Black and white patient differences. Studies are needed to better understand the extent, nature, and causal factors contributing to these inequities in other racial/ethnic groups. The LGBTQ + community experiences significant barriers to healthcare across a range of health conditions including mammography screening [95], cervical cancer screening [96], and abortion care [97]. These barriers are complicated by LGBTQ + hesitancy in seeking care due to a variety of reasons such as lack of cultural awareness and sensitivity by providers and fear of discrimination by providers [98,99]. A systematic review examining culturally competent care for the LGBTQ + community seeking infertility treatment found many studies in their sample emphasized the need for patient-reported suggestions to improve competency in providers [100]. The call for patient-reported suggestions highlights the need for increased uptake of community-based participatory research to meaningfully engage historically marginalized populations while empowering them to be an active participant in the creation of research questions and outcomes to improve accessibility and adherence to care [101]. Current suggestions to improve accessibility include the use of gender-neutral language on forms and signs, the inclusion of all partners for the patients undergoing treatment regardless of their sex, and the breakdown of cis-and heteronormative expectations in healthcare settings [100]. Although some research has been done to explore ways to create more culturally sensitive care, studies examining the implementation of these suggestions and their success are pertinent to ensuring these changes are widespread. Overall, the studies within our sample generally focused only on women with sex and/or gender inequities being sparsely investigated. Although Chandra et al. found that men and women of reproductive age have similar rates of infertility-it was found that male partners do not receive an evaluation a quarter of the time-despite multiple health organizations recommending that both members of infertile couples be evaluated [80,102]. When infertile males were evaluated, one study noted an imbalanced diagnostic process where male infertility is usually only based on seminal analysis. However, female infertility diagnoses explored a broader variety of potential causes [103]. Furthermore, coverage for male factor infertility treatment is also largely excluded from healthcare laws in comparison to females, which disproportionately places the responsibility for reproductive treatment on female partners [104]. In order to provide more equitable access to infertility diagnosis and treatment, Coward et al. recommend further evaluation into defining the population of infertile men and the inequities in accessing treatment [105]. Future policy changes to increase insurance coverage for male infertility diagnosis and treatment, and to create guidelines to increase access to infertility evaluation, is dependent on understanding the full scope of the problem. Rural and under-resourced populations were seldom investigated in our sample. Brodeur et al. found that almost 25 million women in the USA live in areas that do not have nearby access to an ART center and that male infertility specialists are also difficult to come by [106]. Due to a lack of fertility specialists, Chin et al. found that women in rural or under-resourced areas were likely to visit a general practitioner or an OB/GYN for fertility concerns, and were more likely to receive treatments limited to less invasive options such as oral medications [107]. To help improve treatment inequities in under-resourced areas, the American Society of Reproductive Medicine recommended improving education and awareness on the signs and symptoms of infertility and the treatment options, which can help guide patients into their options and allow them to advocate for themselves [108]. For example, the Walking Egg Project aims to bring affordable infertility care to under-resourced populations worldwide. Their project initiative is multidisciplinary in nature and emphasizes the role of education around reproductive health and proper training for providers, in order to create a decreased disease burden and greater understanding of the needs of under-resourced populations [109]. Although investigation into the use of technology to bridge the gap in access for rural and under-resourced populations has seen significant improvement, there is still a lack of research on how to increase access to ART. These gaps are in part due to the nature of the intervention, which requires a significant amount of treatment cycles, numerous phlebotomy-based tests and imaging procedures, and visits to the fertility specialist, creating logistic challenges for patients in under-resourced areas [48]. A recent pilot study-run in collaboration with the Walking Egg Project-investigated the possibility of a simplified culture system for IVF that would reduce the requirement for specialized equipment and decrease costs [110]. The multidisciplinary efforts of this research can allow for collaborative decisions to create individualized treatment plans that patients can commit to and is suitable for their lifestyle, making MAR more accessible. --- Strengths and Limitations In regard to the strengths of our paper, the protocol was written a priori and was strictly followed. To ensure reproducibility and transparency, our protocol and extracted data was uploaded to OSF [13]. All screening and data extraction were performed in a masked, duplicate fashion. Investigators were trained using materials from Cochrane and the JBI, and sample extraction was done to achieve high inter-rater reliability. Our study had several limitations. First, our sample was composed primarily of cross-sectional analyses and findings may not remain relevant over time. Furthermore, it is possible that we did not capture all available literature regarding inequities in MAR due to our inclusion criteria being limited to studies that were in English, completed in the USA, and published between 2016 and 2021. However, Bramer et al. found that searches of both EMBASE and PubMed were sufficient to retrieve 97.5% of the relevant studies [14]. --- Conclusion Our study showed that race/ethnicity, income, and education were the most frequently investigated inequities regarding MAR, while sex or gender, rural/under-resourced populations, and occupational status were the least frequent. We identified research gaps in each of these areas and recommend the following for future research: standardizing and diversifying race/ethnicity reporting regarding MAR, increasing access to infertility care for LGBTQ + populations by providing more inclusive care, increasing access to infertility care for men, and increasing access to MAR for rural/under-represented populations by identifying logistic challenges. --- Data Availability Our entire methodology and protocol were uploaded to Open Science Framework to ensure transparency and reproducibility of results, alongside all of our data. The link to this data is provided in the reference list . --- Code Availability N/A. Declarations Ethics Approval N/A. Consent to Participate N/A. Consent to Publication N/A. --- --- Conflict of Interest

Infertility has a high prevalence in the USA and health inequities play a large role in access to medically assisted reproduction (MAR). The aim of this study was to identify gaps in research pertaining to inequities in MAR and propose suggestions for future research directions. Searches were performed using MEDLINE and Ovid Embase. Articles that reported on MAR inequities, published between 2016 and 2021 in the USA, and written in English were included. The inequities investigated were adapted from the NIH-designated health disparities populations. Each article's inequity findings were extracted and reported, along with frequencies of inequities. Our sample included 66 studies. The majority of the studies investigated MAR outcomes by race/ethnicity and found that historically marginalized populations had poorer outcomes. LGBTQ + populations were less likely to use MAR or seek infertility care. Most studies found positive correlations with MAR use with income and education. The least commonly studied inequities in our sample were sex and/or gender and rural/under-resourced populations; findings showed that men and people from rural/under-resourced populations were less likely to access MAR. Studies that examined occupational status had varying findings. We suggest that future research be targeted toward: (1) standardizing and diversifying race/ethnicity reporting regarding MAR, (2) the use of community-based participatory research to increase data for LGBTQ + patients, and (3) increasing access to infertility care for men.

Introduction About one-third of the world's edible food is lost or wasted annually [1], while the challenge to feed the projected world population of 9.3 billion people by the mid-century will require 60% more food than is currently produced [2][3][4][5]. The Organization for Economic Co-operation and Development identified reducing food waste as an avenue to increase the availability of food [6], while the Obama administration announced in September of 2015 a first ever food waste reduction goal for the United States of 50% by 2030. While present in the entire post-harvest supply chain, food waste at the retail and consumer levels is particularly prevalent in the United States. In 2010 133 billion pounds of edible food at the retail and consumer levels went uneaten with about two-thirds of this waste attributed to consumers [7]. This represents not only a significant waste of resources, but also substantial negative environmental externalities as 95% of food waste enters U.S. landfills. Food waste is the largest source and the most deleterious component of U.S. municipal solid waste [8][9][10][11]. Because so much food waste is attributable to consumers, it is critical to understand consumer awareness, perceptions, opinions, and attitudes that could partly explain the high level of household food waste [12][13][14], so that potential interventions aimed at obtaining new U.S. goals can be assessed and prioritized. However, no models of food waste awareness, perceptions, opinions and attitudes have been estimated for U.S. consumers. We add to the limited consumer food waste literature by estimating such models using responses from a national survey of U.S. residents. Our models are interpreted through the lens of several theories that describe how prosocial behaviors relate to awareness, attitudes and opinions . Our analysis of patterns among respondents' food waste attitudes yields a model with three principal components: one that represents perceived practical benefits households may lose if food waste were reduced, one that represents the guilt associated with food waste, and one that represents whether households feel they could be doing more to reduce food waste. Empirical efforts to assess the relative importance of these key attitudinal responses and principal components and to determine correlations of these key constructs with observable personal and household traits may inform how private and public actions [18][19][20][21] could influence behavior. The existing literature addressing consumer food waste is expanding [22] yet limited and previous work does little to assess the relationships among awareness, attitudes and behaviors. Much of the extant literature summarizes results from regional studies or studies conducted outside the United States [23][24][25][26][27][28][29]. However two studies feature similar data or approaches as our work. Neff, Spiker and Truant [30] report the results from an April 2014 survey, which provides the first national estimates of U.S. consumer awareness, attitudes and behaviors concerning food waste. They report descriptive statistics and pairwise associations between key knowledge, attitude and self-reported behavior measures and several household and personal characteristics, but do not estimate any multivariate regression or principal component models. The second related study is from Stancu, Haugaard and Lähteenmäki [31] who postulate a consumer food waste model which is estimated with survey data. Their work differs from ours in several ways including their reliance on a sample of Danish consumers and their inclusion of meal planning attitudes and self-reported food waste behaviors, which are elements omitted in our work. However, our survey elicits attitudes that assess the perceived practical benefits of food waste, including attitudes linking food waste to perceived food safety, meal freshness, and time savings, which are factors omitted from [31]. To motivate and frame our work, we draw on previous work that attempts to explain prosocial and pro-environmental behaviors. Our survey work presented below clearly shows that most U.S. consumers perceive actions that reduce food waste as pro-social and pro-environmental behaviors, while previous survey work in the United States [30] show food waste reduction is perceived as pro-social by a majority and pro-environmental by more than 40% of respondents. Motivations for most pro-environmental behaviors include a mixture of selfinterested and pro-social motives [17]. Analyses of behaviors with a mix of possible motivations often build from theories such as the Theory of Planned Behavior , the Norm-Activation Model and models that integrate and expand upon aspects of both TPB and NAM such as the Stancu, Haugaard and Lähteenmäki model of food waste behavior [31] and Bamberg and Moser's pro-environmental behavior model [17]. Our conceptual model features three key constructs that arise from our empirical investigation and that are motivated from the theoretical traditions discussed above. The first construct is dubbed Practical Benefits of Food Waste; it draws on the self-interest side of the theoretical literature and will represent the private perceived benefits households accrue by wasting food. The second construct is dubbed Food Waste Guilt and it draws upon constructs of norms and related concepts of guilt. Our third and final construct is dubbed Food Waste Reduction Potential, which is motivated by the concept of Perceived Behavioral Control , a key antecedent of behavioral intentions in the TPB. The remainder of the article is organized as follows. First we discuss our survey instrument and methods. We then provide descriptive statistics and multivariate analysis of key food waste awareness and attitudinal questions. We then present the estimated principal components model and related multivariate analyses, followed by a discussion of the results, implications and limitations of the study. --- Materials and Methods --- Survey Development To enhance comparability with previous research, awareness and attitudinal questions were drafted to measure similar concepts explored by food waste surveys known to the authors at the time of survey development . Prospective language was shared with professional survey developers at the research firm administering the survey, and then revised to accommodate input received. A single awareness question was developed featuring a simple yes/no response . Respondents were coded as 'unsure' only after being read the question twice and volunteering an inability to choose a response. In regression analyses uncertain responses were coded as 0.5. If uncertain responses were instead dropped from the analysis, no statistically significant coefficients change sign, fewer than 7.2% of estimated coefficients change significance status, and fewer than 7.2% of all coefficients change signs. The generation of food waste is a result of multiple behaviors that relate to different aspects of food purchasing, preparation, consumption and post-meal behaviors [32]. Based on literature reviewed above and based on questions implemented in previous surveys [30,32], a slate of nine statements relating food waste to these aspects were presented in the survey . Statements 2, 3 and 8 focus on private, practical benefits that a household may perceive to accrue from throwing away uneaten food such as reduced odds of foodborne illness, improved meal freshness, and time savings; each loads onto the first construct. Statements 1, 4 and 7 focus on potential sources of guilt or norm comparison thought to load onto the second construct. Statements 5, 6, and 9 focus on perceived behavioral control and benchmarking concepts thought to load onto our third construct. Respondents expressed agreement or disagreement on a four point Likert scale . In all analyses, the responses to these questions were recoded from 1 to 4 with larger numbers indicating stronger agreement with the given statement. Respondents were coded as 'unsure' only after being read the question twice and volunteering an inability to choose a response. Uncertain responses occur in 1.8% of responses across these questions and never exceed 4.1% of the total weighted sample for any question. Hence, in all analyses of attitudinal questions uncertain responses were dropped. Four other questions concerning food waste were asked as part of this survey, but are not the focus of this analysis and so are excluded from this article. --- Sampling and Implementation The survey was administered by SSRS as part of a weekly national dual-frame telephone omnibus study conducted by the firm via computer-assisted interviewing. The sample is designed to be representative of the United States and features a fully-replicated, stratified, single-stage random-digit-dialing sample of landline telephone households, and randomly generated cell phone numbers. About 3 to 4 percent of interviews are conducted in Spanish to facilitate proper representation of the Hispanic population. The response rate reported by SSRS is approximately 8%, which is common for large national omnibus surveys that are conducted on a weekly basis and do not allow for follow ups beyond the week the survey is launched. Recruitment scripts for the survey do not mention food waste or the other focal topics featured on this multi-topic survey, which may reduce the tendency for those motivated by topics such as food waste to volunteer for the survey and, hence, may mitigate self-selection bias. The vendor made six attempts to contact each sampling unit and used Spanish-speaking interviewers once a household is identified as Spanish speaking. We note that Neff, Spiker and Truant report a response rate of 51%, though this figure is the response rate among online panel members previously recruited to be members of the online panel, and no information is provided about the percent of recruits to online panel membership that become panel members. Hence, direct comparisons between response rates for the two studies are complicated by the different survey sampling methodologies employed. Unless otherwise noted, analyses are conducted with weights designed to create nationally representative and projectable estimates of the adult population 18 years and older on age-by-gender, race and ethnicity, census region, population density of county of residence, and education. In addition to our slate of questions concerning food waste, each respondent answers questions posed by other clients contracting with SSRS during the week the interviews were conducted. The order of our group of questions is randomized with those from other contributors to the survey, whose identity and questions are unknown to the authors. Each survey ends with a broad array of questions focused on personal and household characteristics of the respondent. Telephone interviewers were personally briefed and trained on our slate of questions before conducting the interviews. Mock interviews were conducted to ensure that interviewers followed all procedures correctly and consistently. In addition, throughout the week of administration, SSRS field personnel and project directors continually monitored the interviewers to ensure that diction and probes are consistent across interviewers. --- Analysis Analyses were conducted in SAS 9.3 and Stata 13.1. To understand common patterns among attitudinal responses we extract principal components . Prior communality estimates are set to one and components with an eigenvalue less than one are dropped from the analysis. A varimax variable rotation is used to arrive at the principle components presented in the results section. Significant loadings onto a principle component are defined as those with a loading greater than 0.40 in absolute value. In order to refine our understanding of the associations between respondents' awareness and attitudes and respondents' personal and household characteristics, we conduct multivariate regression analyses . An ordered logit regression was used for the awareness response and to model agreement with individual statements listed in Fig 1 . Ordinary least squares regression was used to model associations between characteristics and principal components extracted from the attitudinal responses. Control variables, which are the same across all the regression models, include household demographics covered in existing food waste literature, such as education, income, age, gender, marital status, household size and composition, employment status, urbanicity and region [27,30]. Other variables are also included that feasibly affect food waste awareness and attitudes. Home ownership is included as it is strongly correlated with U.S. residential size: owned residences feature greater total square footage , per person square footage , and lot size . Residence and lot size may influence whether respondents can invest in items associated with food storage, leftover storage, and food waste handling such as larger refrigerators, stand-alone freezers, greater pantry space, or outdoor composting sites. Given attitudinal questions exploring feelings of guilt, we include religious affiliation as a possible control variable. We include race as a possible control for different food preferences and different food preparation and dining habits. We use a 5% level to determine statistical significance and denote the p-value of variables in all tables. --- Ethics Statement This study and its consent procedure were reviewed and approved by the Ohio State University Institutional Review Board. Survey respondents contributing to this study provided verbal consent to participate in the questions asked while survey recruits that did not consent were not asked any study questions. --- Results We first report descriptive statistics for all variables and compare these to recent U.S. survey work before discussing results from multivariate models of each individual awareness and attitudinal response. We then present the principal components analysis and accompanying multivariate analysis of associations with personal and household characteristics. Key personal and household characteristics of the unweighted sample are listed in Table 1 and compared to national figures. While the unweighted figures align well with national averages on several characteristics, survey weights are applied to all subsequent analyses to further refine the representativeness of the sample. --- Awareness A modest majority of the weighted sample answered 'yes' when asked "In the last 12 months, have you read, seen or heard anything about the amount of food that is wasted or about ways to reduce the amount of food that is wasted?" Of the remaining respondents, 39% responded 'No' with the remaining 8% uncertain. Neff, Spiker and Truant asked their respondents a similar question: "In the past year, have you seen or heard anything in the news, Due to rounding, some categories do not sum to 100 percent. a Percentage is based on the population over 18-year-old, not total population. b Some college includes people who have some college credits but failed to graduate, and people with degrees from technical school/other which account for 1.6% of the sample. c Household Income figures represent percentages of those who provided information for this question. 63 of the 500 respondents refused to answer this question. Source for US data: United States Census Bureau. doi:10.1371/journal.pone.0159250.t001 social media, or elsewhere about the issue of food that is thrown out or otherwise not eaten by humans? ." 42% answered 'yes' to this question, which is 11 percentage points lower than our sample's awareness response, a difference that is statistically significant . --- Attitudes and Opinions Respondents' agreement with the slate of nine food waste attitudinal statements is listed in Fig 1 . The order of the statements as read to respondents was randomly assigned to mitigate possible order effects. Uncertain responses only average 1.8% across these questions and never exceed 4.1% of the total weighted sample for any question, which accounts for a much smaller percentage of the sample than 8% uncertain respondents in awareness question. Hence, to simplify exposition, uncertain responses are dropped, and percentages reported in this section represent the percent of respondents able to articulate a response to each statement. Respondents express the highest degree of agreement with the statement linking guilt to throwing away food, with more than three quarters agreeing either strongly or somewhat. The next strongest agreement is with a statement suggesting that throwing away food if the food package's date has passed helps reduce the odds of foodborne illness. More than two-thirds of respondents express agreement despite increased press coverage of scientific literature suggesting that label dates are not a good proxy for foodborne illness threats [35,36]. The next strongest agreement is with a statement that some food waste is necessary to ensure meal freshness and quality followed by a statement that throwing away food is bad for the environment . Respondents are about equally split between agreeing and disagreeing with statements that food waste is exacerbated by bulk and sale purchases and that it would be difficult for their household to reduce food waste further . A minority agrees that changing household food waste levels would induce significant changes in money or time costs, with 42.1% agreeing food waste is a major source of wasted money and 24.1% agreeing that they do not have enough time to worry about food waste. Only 13.6% agree that their households waste more food than other households of their size. These results align with the results presented by Neff, Spiker and Truant on several fronts. 65% of Neff, Spiker and Truant's sample agree that they worry about food poisoning when making food discard decisions, which aligns closely with the 69.7% in our sample that agreed that food waste can reduce the risks of foodborne illness. At the 5% level we fail to reject equality of the proportion of respondents expressing agreement on this topic between our survey and the Neff, Spiker and Truant survey . Similar percentages of respondents also agree that food waste is important for ensuring meal quality and freshness . The two samples contrast on responses to questions linking food waste to financial waste in respondent households, though the question wording between the surveys was not as closely aligned. For the Neff, Spiker and Truant sample, 63% disagrees with the statement "I don't think the amount of food I throw away costs me much money" while 42.1% of our sample agrees that "Throwing away food is a major source of wasted money in your household," z = 7.26, p <0.001). A minority of both samples agree with statements linking a lack of time to the amount of food they waste, though the level of agreement is higher in our sample with the difference being statistically significant . Finally, few in either sample viewed their own level of food waste to be above average . The wording of questions that assess guilt and environmental motivations about household food waste is less comparable between the Neff, Spiker and Truant study and ours. However, a similar pattern emerges where general guilt towards food waste appears to dominate specific concerns about the environment in both studies. For example, in Neff, Spiker and Truant, those reporting that 'guilt about waste in general' as an important motivation for reducing food waste is around 60%, while only about 40% cite greenhouse gases, energy and water as an important motivation; that is, general guilt sentiments exceed environmental concerns by about 20 percentage points. In our sample, there is also about a 20 percentage point gap between those agreeing that they feel guilty about food waste and those agreeing that throwing away food is bad for the environment . --- Associations with Personal and Household Characteristics Results from an ordered logit regression model of food waste awareness are reported in Table 2. While Neff, Spiker and Truant do not report tests results for association between awareness and household demographics, they report two significant associations between food waste knowledge and demographics. Specifically, they find those 65 years of age or older express significantly greater knowledge of food waste than those younger than 65, while we find no significant differences in reported awareness across age groups in our regression results. Also, Neff, Spiker and Truant find that households with children under 18 years of age have significantly less knowledge than other households, where we find awareness to be significantly negatively associated with the number of children in a household. We find the employment status variables are jointly significant, with part-time and retired respondents revealing significantly higher awareness than those employed full time. This may reflect that those employed full time have less time or focus available to generate awareness of this issue. While the education variables are not jointly significant, the results do reveal that the omitted group is significantly associated with less awareness than those who have received more formal education. Multivariate ordinal regression analyses of the association between the attitudinal and opinion statements and respondent characteristics reveal several statistically significant results . For example there is a statistically significant association between gender and agreement with the statement that the respondent feels guilty when throwing away food, with women more likely to agree with this statement . Likewise, those who reveal awareness of the food waste topic are also more likely to agree with this statement . A respondent's education is associated with agreement with the statement linking food waste to environmental harm with those who obtain higher levels of formal education expressing stronger agreement. Those with more formal education are also more likely to agree with the statement linking bulk purchases to increased household food waste . Employment status is jointly significantly associated with a respondent's agreement with the statement saying the respondent doesn't have enough time to worry about food waste with those who are temporarily unemployed, disabled, handicapped, and other not employed featuring the strongest disagreement . Finally, there is a jointly significant association between a respondent's region and a respondent's agreement that their household tends to waste more food than other similarly sized households with those from the South and West expressing the least agreement. The first principal component features three significant loadings related to agreement with the statement that there isn't enough time to worry about food waste , that food waste is necessary to ensure meal freshness and quality and that throwing away food whose package date has passed can reduce the chances of foodborne illness . The 'Practical Benefits of Food Waste' component increases as they perceive that wasting food can deliver practical household benefits . This component aligns with constructs representing the perceived personal benefits for wasting food and costs associated with reductions in food waste. According to the TPB, the balance of such perceptions helps generate attitudes toward the behavior that influences behavioral intentions and, potentially actual behavior. Wasting food may generate several private benefits for a household. Households may perceive that throwing out uneaten food will minimize health risks from foodborne illness or enhance meal quality by avoiding the use of less fresh food . Respondents may generate food waste as a result of having saved time earlier in the meal planning and preparation stages . We note this construct is absent in Stancu, Haugaard and Lähteenmäki's [27] model of consumer food waste. The second retained component also features three significant positive loadings. The largest loading is from the variable in which respondents agree that they feel guilty for throwing away food , followed by agreement with the sentiment that throwing away food is bad for the environment and that throwing away food is a major source of wasted household money . This 'Food Waste Guilt' component overlaps with norm constructs from several theories mentioned earlier. The positive loading on the statement linking guilt to throwing away food suggests such sentiments arise from the respondents perceiving food waste as a deviation from a norm against wasting food. The positive loading on the statement linking food waste to environmental harm may come from those who view protecting the environment as a norm. Finally, the positive loading on the statement identifying food waste as a source of wasted household money may stem from those who view household financial waste as a deviation from norms of household financial prudence. However, in each case, our instrument cannot distinguish whether the norm potentially invoked is a social or a moral norm. Social norms are postulated to influence behavioral intentions in the TPB while the NAM postulates moral norms as a direct influence on behavior. Bamberg and Moser's pro-environmental behavior model [17] postulates that social and moral norms both contribute to behavior, though their empirical application reveals a direct statistical linkage between moral norms and behavioral intentions and only an indirect statistical linkage for social norms via attitude formation. Throwing away food could feasibly activate norms on several fronts including environmental, financial or household management. Stancu, Haugaard and Lähteenmäki [31] feature a moral norm construct with loadings from two statements focused on guilt, though their moral norm construct has no positive association with intentions to reduce food waste for their sample of Danish consumers. The final retained component also features three significant loadings. The largest loading is positive and denotes agreement with the statement that the respondent's household wastes more food than similarly sized households. The second largest loading is negative and signals that respondents disagree that it is difficult to further reduce food waste . The final significant loading is positive and denotes agreement with the statement that buying in bulk or during sales can lead to greater food waste. This 'Food Waste Reduction Potential' component may represent a blend of constructs from the theories mentioned above. The component loads positively on agreement with the statement that the respondent's household wastes more food than similarly sized households, yielding the clearest assessment of deviation from benchmark behavior. This suggests a possible link to a social norm, though the instrument doesn't assess whether the respondent views deviation in the amount of food waste as a breach of social norms per se. The component loads negatively on agreement with a statement that it would be difficult for the household to further reduce food waste, which speaks to the construct of Perceived Behavioral Control mentioned previously. Finally, a significant positive loading for the component comes from agreement that buying in bulk leads to more wasted food in their household. This may be a precursor to PBC as those who agree with this statement essentially admit to a consumption pattern that exacerbates food waste and, hence, acknowledge one possible means by which they can increase the pro-social behavior of reducing food waste. PBC is influenced by past experience as well as perceived barriers of the behavior, which influences the perceived difficulty of engaging in the behavior. These perceptions of control may be influenced by benchmarking exercises in which households compare their behavior with that of other households. Such benchmarking has been shown to be relevant in pro-environmental behaviors such as energy conservation [28,29] and may feature some conceptual spillover with social norm constructs. We note that Stancu, Haugaard and Lähteenmäki [27] features a PBC construct in their model, but they do not consider household benchmarking. For each respondent, we predict each retained component score and then regress the predicted scores against the array of personal and household characteristics outlined earlier. Results are presented in Table 3 and feature several significant associations that merit discussion. Income is jointly significant in the regression for the first component and reveals that the highest income group is associated with the highest predicted scores for the 'Practical Benefits' component. For the 'Guilt' component the race category is jointly significant. Those identifying as Asian or identifying with other racial groups score highest on this component. Employment status and region of residence are jointly significant for the 'Food Waste Reduction Potential' component. Respondents who reside in the West scored lowest on this component as did those identifying as a student or homemaker. --- Discussion and Implications The congruence of several findings between our results and those in the literature suggests an emerging set of core stylized facts about U.S. consumer awareness and perceptions. There is an emerging sense that awareness of food waste is high but not nearly universal; that most households feel guilty about food waste; and that these general feelings of guilt about food waste clearly exceed specific concerns about negative effects of food waste on the environment. There also appears to be consensus that a majority of households find that enhancing meal safety and freshness may sometimes require wasting food. We look forward to future work that can continue to track and refine these findings and insights. To our knowledge, we are the first to apply principal component analysis to attitudinal responses of U.S. consumers concerning food waste to form composite constructs. The three retained components align with theoretical constructs invoked to explain pro-social and pro-environmental behaviors elsewhere in the literature. We look forward to future research to see if others identify similar commonalities in attitudinal responses and how these are related to intended, self-report and objectively measured food waste behaviors. If a consistent set of components can be identified, it can facilitate the development of tractable behavioral models of consumer approaches to household food waste issues. Such models could inform the development and targeting of informational or other policy interventions that focus on these constellations of issues. For example, in Table A in S1 File we identify that those who express awareness of food waste are significantly more likely to agree that they feel guilty when throwing away food, and this statement loads positively on the Food Waste Guilt component. Guilt, defined as ". . .the negative affective experience aroused when one's behavior falls short of social or moral norms. . ." [37,38], plays a critical role in self-regulation and functions as a motivator to keep behaviors in line with perceived standards [39]. Neff, Truant and Spiker note that 60% of their sample agree that they try to reduce waste because of guilt. Together, this could suggest a possible pathway to reduce food waste that begins with awareness, which generates guilt by delineating a moral norm that can then lead to household food waste reduction efforts. This hypothesis is supported by the norm-activation model [16] that regards moral norm as direct determinants of pro-environmental behaviors. The formation of a moral norm, which delivers the standard about what are the right things to do, is an interaction of cognitive, emotional and social factors. Awareness and knowledge about food waste are likely to be crucial cognitive antecedents for the development of moral norms. However, moral norms may not drive intended or actual behavior with respect to food waste, as Stancu, Haugaard and Lähteenmäki [31] find no significant association between their moral norm construct and intended food waste behavior for Danish consumers. Whether such associations are unique to Danish consumers or also apply to U.S. consumers in the food waste context must be addressed in future work. Our results also point to another informational avenue that can build on this norm-based strategy to reduce food waste. Both our study and that of Neff, Truant and Spiker reveal that the vast majority of respondents view their food waste as average or less than average, which suggests that few people identify current behavior as a deviation from social norms. Interventions that measure a household's food waste level and place it in perspective of societal averages or a socially-endorsed goal could result in stronger norm activation, more positive attitudes towards reducing food waste, and stronger intentions to reduce food waste, which could lead to improved behaviors . Interventions by energy companies that measure household energy usage and report the household's usage compared to that of neighbors have yielded reductions in energy usage across all households involved [40,41], though similarly effective household-level measurement technology is currently lacking in the realm of food waste. The regression analysis in Table 3 also reveals that higher income households tend to score higher than other income groups on the Practical Benefits component, which indicates strong agreement by the respondents with the ideas that food waste is needed to ensure fresh, high quality meals, to reduce foodborne illness, and to economize on time. These insights align with economic intuition, in that higher income households have a high opportunity cost for their time and generally demand goods perceived to be higher quality . Given these general demand patterns among higher income households, informational treatments aimed at such households that communicate simple ways to circumvent the perceived freshness versus food waste trade off may stimulate lower food waste among such households. Also, such households may be particularly responsive to initiatives that remove or clarify food label dates, which may mitigate food labelling confusion and alleviate perceived trade-offs between food waste and foodborne illness [42]. According to the regression results shown in Table 3, those identified as the 'other' race are significantly more likely to score higher than other groups on the principle component dubbed food waste guilt, implying agreement with linkages between throwing away food and guilt, environmental degradation, and wasted household money. Similar patterns are also found in agreement that more food is wasted when food is bought in bulk . For those who identify as 'other race,' about half list ancestral affiliation with Asia, with most arriving from or having ancestors who arrived from developing countries where food or other resources may be scarce and social norms against wasting food or other resources may be stringent. Therefore, people from those countries may be more self-regulating and be more aware of the source of food waste. For example, Japan, South Korea, and Singapore, which are among the few developed economies in Asia, have very strict waste recycling systems because of the scarcity of natural resources. Indeed, the South Korean government charges residents per unit of food waste created [19]. Other developing countries, like China, may have strong cultural norms about saving food because of historical food shortages, and recent press coverage urges an end to food waste at business meals [43]. --- Limitations One limitation of this study is that we do not assess self-reported individual food waste behaviors, which often yield downwardly biased estimates of household food waste as consumers may tend to report what is closer to perceived moral norms than to the actual amount [44,45]. Another limitation is our use of home ownership as a proxy for a household's ability to invest in food storage. The response rate to this omnibus phone survey is 8%, and represents another of the study's limitations. Phone surveys can yield higher response rates, but we relied upon the omnibus survey platform provided by our vender, where all recruited respondents must finish the survey during the same week they are first contacted. Due to limited funding, we also rely upon a smaller sample size than previous national surveys . Finally, both our work and that of Neff, Truant and Spiker rely on cross sectional data. Additional research that can track a panel of individuals over time or provide another source to identify causal linkages would be required to validate the pathways conjectured in this and other work. We also note our ability to compare our sample's awareness and attitudinal responses to those of Neff, Truant and Spiker's sample faces some limitations. For example, it would be ideal to track any changes to U.S. consumer awareness of food waste issues in the 15 months between the two surveys. We find general awareness of food waste to be 11 percentage points higher in our sample than in Neff, Spiker and Truant's sample, but differences in awareness could be related to several factors beyond population change. We employ a different sampling method , administer the survey via a different interview mode , and use different wording to assess key awareness and attitude constructs. For example, our awareness question was more broadly worded and mentions '. . .ways to reduce the amount of food wasted. . .' while Neff, Spiker and Truant's question is more narrowly focused on waste alone. --- Conclusions If the United States is to reach its recently announced goal of reducing food waste by 50% by the year 2030, U.S. consumers must be an integral part of any successful plan, either by directly altering their household food waste behaviors or by inducing other actors in the food supply chain to reduce food waste. Our survey results suggest that the first step to engaging U.S. consumers-generating awareness of food waste-has surpassed the 50% mark. It also suggests that increasing public concern about the environmental threat posed by wasted food may be an important early step, as we document that specific concerns about the environmental harm posed by food waste lag considerably behind general feelings of non-specific guilt about food waste. Food label guides or initiatives like the removal of sell-by dates could help reduce food label confusion and alleviate the perceived tradeoff between food waste and foodborne illness, which may be able to reduce some food waste efficiently. Such an information initiative could be especially effective among high income households and females who waste food because of health concerns but strongly feel guilty about food waste at the same time. While assessing consumer awareness, attitudes and opinions concerning food waste provides important information for assessing potential information and other policy interventions, additional work to refine and simplify physical measures of food waste at both the household and more aggregate levels will be critical for further in-depth consumer studies and improving the implementation and tracking of food waste reduction interventions. Supporting Information S1 File. --- All relevant data are within the paper and its Supporting Information files.

We estimate models of consumer food waste awareness and attitudes using responses from a national survey of U.S. residents. Our models are interpreted through the lens of several theories that describe how pro-social behaviors relate to awareness, attitudes and opinions. Our analysis of patterns among respondents' food waste attitudes yields a model with three principal components: one that represents perceived practical benefits households may lose if food waste were reduced, one that represents the guilt associated with food waste, and one that represents whether households feel they could be doing more to reduce food waste. We find our respondents express significant agreement that some perceived practical benefits are ascribed to throwing away uneaten food, e.g., nearly 70% of respondents agree that throwing away food after the package date has passed reduces the odds of foodborne illness, while nearly 60% agree that some food waste is necessary to ensure meals taste fresh. We identify that these attitudinal responses significantly load onto a single principal component that may represent a key attitudinal construct useful for policy guidance. Further, multivariate regression analysis reveals a significant positive association between the strength of this component and household income, suggesting that higher income households most strongly agree with statements that link throwing away uneaten food to perceived private benefits.

Methods: Female postpartum respondents to the 2006 Canadian Maternity Experiences Survey were classified as living in rural , semirural , semiurban or urban areas. We further subdivided women living in rural areas based on the social and occupational connectivity of their community to larger urban centres. We compared the prevalence of postpartum depression across these groups and adjusted for the effect of known risk factors for postpartum depression. --- Results: The prevalence of postpartum depression was higher among women living in urban areas than among those living in rural, semirural or semiurban areas. The difference between semiurban and urban areas could not be fully explained by other measured risk factors for postpartum depression . In rural areas, there was a nonsignificant gradient of risk: women with less connection to larger urban centres were at greater risk of postpartum depression than women in areas with greater connection. Interpretation: There are systematic differences in the distribution of risk factors for postpartum depression across geographic areas, resulting in an increased risk of depression among women living in large urban areas. Prevention programs directed at modifiable risk factors could specifically target women living in these areas to reduce the rates of postpartum depression. nity Experiences Survey 11 ); this survey was performed by the Public Health Agency of Canada and the Canadian Perinatal Surveillance System. This national cross-sectional survey collected information on key perinatal health indicators from recent mothers in all provinces and territories using the 2006 Canadian Census sampling frame. Sampling was stratified by province or territory to ensure adequate sample size in specific groups, and certain vulnerable groups and low population-density regions were oversampled to ensure adequate sample size for the analysis of those groups. A simple random sample without replacement was drawn from each stratum. 11 Mothers living on First Nations reserves and in collective dwellings were excluded from the sampling frame. The response rate was high , and the responses were collected by use of computer-assisted interviews with women who had a singleton birth between Feb. 15 and May 15, 2006, in the provinces and between Nov. 1, 2005, and Feb. 1, 2006, in the territories. The included mothers were all over the age of 15 years and were living with their child at the time of the interview. The response rate was 78% , representing about 76 500 Canadian women . For the present study, Health Canada's Science Advisory Board and Research Ethics Board and the Federal Privacy Commissioner reviewed the research protocol, and approval was received from Statistics Canada's Policy Committee before implementation. We accessed the data through an application process to the Social Sciences and Humanities Council of Canada. Our study was also approved by the Research Ethics Board at the Centre for Addiction and Mental Health in Toronto, Ontario. --- Exposure definitions Our definitions of rural and urban areas were based on a Canadian framework for defining rurality advanced by Statistics Canada. This framework uses strategies that capitalize on potential differences between communities, not only in terms of population size, but also in terms of social and occupational connectivity with larger centres. 10,12 We used 3 methods to define rural and urban areas: population size and density; population size of an area's urban core ; and the proportion of individuals in rural areas who commute to larger urban centres . We defined rural populations as those outside settlements of 1000 or more people or outside areas with a population density of 400 or more inhabitants per square kilometre. We further classified remaining women as living in semirural , semiurban or urban areas. In our secondary analyses, we used additional definitions from Statistics Canada that better reflect the degree of connectivity of small towns to larger urban settings in a way that is not captured by population size alone. In this definition, individuals living within census metropolitan areas and census agglomerations are considered to be living in a "larger urban centre." In Canada, a census metropolitan area has a total population of 100 000 or more people, with 50 000 or more in the urban core, and a census agglomeration has an urban core of 10 000 or more people. Both include neighbouring towns and municipalities where 50% or more of the workforce commutes to the urban core. 13,14 Individuals living outside census metropolitan areas and census agglomerations are classified as living in "rural and small town" areas. To separate the women with the most potential for social isolation from those with less potential for isolation, we further divided women living in rural and small town areas by "metropolitan-influenced zone." These zones indicate the percentage of residents who commute to larger urban centres. The zones are designated as strong , moderate , weak or no metropolitan influence. 10,15 Outcome measures Our primary outcome was postpartum depression, as measured by use of the 10-item Edinburgh Postnatal Depression Scale, 16 which was administered to all survey respondents. This is the most widely used screening questionnaire for postpartum depression, and it has good discriminant validity. The risk of postpartum depression is increased more than 10 times among women who score ≥ 13 points. 17 --- Covariates The Maternity Experiences Survey contains information about sociodemographic and medical characteristics and health service use. The variables of interest were age, parity, marital status, socioeconomic status, education status, country of birth , recent immigration , distance travelled to give birth, history of depression, life stressors, abuse, social support during pregnancy and the postpartum period, substance and alcohol use, type of antenatal care provider, and complications during pregnancy, delivery and the perinatal period . --- Statistical analysis The data were analyzed using SAS version 9.3 at the Toronto Region Statistics Canada Research Data Centre. We used population weights sup-plied by Statistics Canada to weight all estimates to represent the population at the time of the survey. To account for the complex cluster-sample design of the survey, we used a weighted bootstrapping resampling procedure to calculate the coefficients of variation for the estimates. We did not report estimates for which the coefficients of variation were greater than 33.3%, because this indicates a high likelihood of bias in the esti- mate. 18 We calculated the weighted prevalence of postpartum depression for the entire population and subsequently for the exposure groups using each definition of rurality. We described and compared the prevalence of postpartum depression among women living in rural, semirural, semiurban and urban areas. We then generated adjusted odds ratios and 95% confidence intervals using the urban group as the referent category. We adjusted the multivariable models for known risk factors of postpartum depression , 19 as well as for covariates for which clinically significant differences were observed between groups for potential prognostic variables. In our secondary analysis, we compared the prevalence of postpartum depression among women living in rural and small town areas to the prevalence among women living in large urban centres. Among women who lived in rural and small town areas, we compared the prevalence of postpartum depression between women living in areas designated as having strong, moderate, weak and no metropolitan influence. --- Results The weighted prevalence of postpartum depression in the overall sample was 7.47% , and the weighted mean score on the Edinburgh Postnatal Depression Scale was 5.27 . Descriptive characteristics are shown in Table 1. Compared with women in the urban group, women in the other groups were slightly younger, more likely to be born in Canada and less likely to receive their obstetrical care from an obstetrician . Compared with women who lived in urban areas, women in the other groups were less likely to have postsecondary education and to be in the highest income quintile. Over 50% of women in the rural group and 44% of women in the semirural group indicated that they had to travel outside of their community to give birth . Women in urban areas reported lower rates of depression history and fewer stressful life events compared with women in the other groups. However, a smaller proportion of women in urban areas reported that they were in excellent or very good health, and they were less likely to report adequate social support during pregnancy and the postpartum period. The prevalence of postpartum depression varied depending on urban, semiurban, semirural and rural area, as did the mean score on the Edinburgh Postnatal Depression Scale. Women in the urban group were at higher risk of postpartum depression than women in the other groups . When we compared women in the rural and small town group with those living in larger urban centres, women in the latter group had nonsignificantly higher prevalence of postpartum depression and mean score on the Edinburgh Postnatal Depression Scale . There were no statistically significant differences in the prevalence of postpartum depression among women living in rural areas when we examined prevalence by level of influence from a metropolitan zone. There was a nonsignificant gradient in which the prevalence was highest among women in areas with weak metropolitan influence. There was a slightly lower prevalence among women in moderate zones, and prevalence was lowest among women in strong metropolitan-influenced zones . The mean scores on the Edinburgh Postnatal Depression Scale followed similar trends . After adjusting for known predictors of postpartum depression and possible prognostic variables for which we found clinically significant differences, we were able to explain the higher risk among urban women, but not for the lower-risk women in the semiurban group, who remained at significantly lower risk of postpartum depression than women in the urban group . --- Interpretation We found that Canadian women who lived in large urban areas were at higher risk of postpartum depression than women living in other areas. The risk factors for postpartum depression that were unequally distributed across geographic regions accounted for most of the variance in the rates of postpartum depression. Combining women in large urban areas with those who lived outside rural and small town areas obscured differences in the rates of postpartum depression across geographic regions, suggesting that more sophisticated definitions of urbanicity are required for research in this area. The overall prevalence of postpartum depression of 7.47% in this study is lower than the traditionally reported rates in developed countries , 8 but this rate is consistent with the prevalence reported in other population-based studies conducted in the latter part of the first postpartum year. 8 The prevalence rate that we observed among women in rural areas was substantially lower than the combined prevalence rate of postpartum depression of 21.5% among rural women observed in our previous meta-analysis on this topic. 10 However, most of the studies included in the systematic review involved selected populations with many risk factors for postpartum depression , which would potentially inflate the prevalence estimates. Only 3 of the studies in the systematic review included comparison groups of women living in nonrural areas; the results of these studies were more con-Research CMAJ, September 17, 2013, 185 1133 sistent with the results of the current study. Two studies found no significant differences in the risk of depression at 6-8 weeks postpartum. 20,21 In the third study, Australian women from nonmetropolitan areas had significantly lower odds of depression at 8-9 months postpartum than did women living in metropolitan areas . 22 These results are not surprising, because outcomes can change depending on the definition of the rural exposure group. --- Limitations As with most population-based surveys, the potential limitations include the self-reported nature of the data, as well as the potential for a sampling bias of healthy respondents . The sampling frame excluded women living on First Nations Reserves or in group dwellings. Although the psychometric properties and predictive validity of the Edinburgh Postnatal Depression Scale as a measure of postpartum depression have been well-established, diagnostic confirmation for postpartum depression was not available. Because of the cross-sectional nature of the data, we can only hypothesize about causal pathways to explain the observed variability in postpartum depression across regions of different population size. We were limited to the variables collected in the survey. Certain elements important to social support and social capital such as marital discord and access to supportive resources may not have been captured by the 4-item social support scale. This may explain why we were unable to account for all of the observed variability in the risk of postpartum depression across geographic regions. --- Conclusion Our study helps to clarify the relation between place of residence and risk of postpartum depression in Canada. Our findings suggest that women in urban areas with a large population were at increased risk of postpartum depression compared with women in other regions. Geographical differences in the distribution of important risk factors for postpartum depression, such as immigration status, interpersonal violence, selfperceived health and social support, account for much of this variance. Supports and services targeted toward increasing connections for isolated women in large urban centres may need to be increased in Canada. Considering the substantial negative effect of postpartum depression, such interventions could have broad-reaching social and public health impact. Other countries might also benefit from studying the levels of perceived social support across regions, particularly in cases where geographical variation in the rates of postpartum depression is observed. Further, our results show that careful consideration of the definitions of rurality and urbanicity is essential because of the way the results depend on how geographical exposure is defined.

ostpartum depression is an internationally recognized health concern for women and their families. Depression during the perinatal period is associated with serious negative consequences for both mother and baby, particularly if the depression is untreated. 1 Outcomes among women include impaired functioning, poor quality of life and death. 2 Outcomes for infants include developmental delay, poor growth, malnutrition and illness. [3][4][5] Numerous risk factors for postpartum depression have been identified; low levels of social support and history of depression are among the variables most consistently associated with postpartum depression. 6-8 However, previous reports are inconsistent as to whether geographical size or location is associated with the risk of postpartum depression. 9 In Canada, about 30% of the population lives in rural or remote areas, a large proportion live in several large urban areas, and the remainder live in smaller urban settings. 10 To design appropriate supports and services for the prevention and treatment of postpartum depression among Canadian women, it is important to identify and target geographical variation in the risk of postpartum depression. Our primary objective was to compare the risk of postpartum depression among Canadian women living in rural and urban areas. Our secondary objective was to identify factors that could explain any associations between place of residence and risk of postpartum depression. We used multiple definitions of rural and urban locations to more accurately reflect differences between communities and to account for the level of social and occupational connectivity of smaller areas to more urban areas.We used a population-based Canadian survey of women who had recently given birth (the Mater-

Introduction: The COVID-19 pandemic, caused by the SARS-CoV-2 coronavirus, has dramatically influenced society and economy worldwide. Its consequences have been felt in a variety of industries, including the food business, where street food sellers play an important role. Street food sellers are an important part of Kolkata's dynamic culinary culture, delivering a wide range of delectable foods to locals and tourists alike. The purpose of this research is to shed light on the specific effects of COVID-19 on Kolkata Street food sellers. As the pandemic progressed, these vendors, who were frequently operating in densely populated neighborhoods and bustling markets, encountered various obstacles. The limits and safety procedures put in place to stop the virus's spread had a profound impact on their livelihoods and the whole street food ecosystem. The flavors, fragrances, and cultural significance of Kolkata's street food scene are legendary. Puchka , kathi rolls, jhal muri, and other exquisite desserts are popular in the city. Street food vendors are an important component of this culinary scene, supplying people from all walks of life with economical and delicious meal alternatives. Their companies are frequently dependent on foot traffic, crowded markets, and the lively ambiance of the streets. However, the arrival of COVID-19 caused a significant shift in the street food industry. Lockdowns, social distancing norms, and restrictions on public gatherings all had a significant influence on the operations and revenue of street food sellers. Fear of infection, along with a drop in footfall, worsened their problems, resulting in huge financial losses and uncertainty about their future. This research will investigate the various consequences of the epidemic on Kolkata's street food sellers. It will examine the economic ramifications, such as lost income, decreased client demand, and increased operational expenses due to cleanliness and safety regulations. The study will also investigate the social and psychological dimensions, such as the mental health toll, societal stigma, and the resilience displayed by these vendors in the face of adversity. This study aims to give significant insights to policymakers, local authorities, and key stakeholders by analyzing the specific issues experienced by street food sellers in Kolkata during the COVID-19 pandemic. The findings can help to establish targeted interventions, support systems, and policy reforms to lessen the impact of future crises on street food sellers and ensure the sector's long-term viability. Finally, this study recognizes the importance of street food vendors in Kolkata's culinary fabric, as well as their vulnerability to the COVID-19 pandemic. By investigating the economic, social, and psychological components, we hope to develop knowledge that might drive efforts to safeguard and empower these sellers, allowing them to overcome the pandemic's obstacles and continue to enrich Kolkata's dynamic street food culture. --- The Objective of the Study: 1. To Analyse the street food vendor's financial struggles. 2. To Examine the consumer perception towards Street food Vendors. --- Research Methodology: • Research Design: The primary data survey will be designed as a cross-sectional study. It intends to collect data at a given point in time to acquire information on the effects of COVID-19 on Kolkata's street food vendors. This design allows for the investigation of various factors and their interactions over a set period. • Sampling Method: For this survey, a combination of convenient sampling and stratified sampling will be used. Initially, a list of Kolkata Street food sellers would be developed utilizing existing databases, municipal governments, and related groups. A random selection of merchants will be chosen from this list to ensure representation from all sections of the city. Stratified sampling will be used to achieve an appropriate distribution across various locations and types of street food vendors . Data Presentation, Analysis, and Findings: --- DIFFERENT SERVICE TIME --- Consumer's preference • Consumers like Indian and Chinese cuisine from street vendors. • The majority of customers choose to get their evening refreshments from street food sellers. • Following the epidemic, consumers' demand for street food has progressively increased, and as a result, vendor sales have soared. • A competent market vendor should be satisfied with their business and strive to expand it. --- Limitations of the Study: The study's findings may be limited in generalizability due to convenience sampling and stratified sampling techniques. It is important to consider the potential for biases and limitations in the accuracy of the data collected, such as self-reporting bias, recall bias, and limited scope. --- Conclusion: 1. According to the findings of this study, the COVID-19 epidemic has had a significant impact on Kolkata's street food vendors. However, it is obvious that suppliers have responded to changing conditions by instituting hygiene and safety practices, which have helped recover client trust. Demand for street food has gradually increased, resulting in higher sales and earnings for many vendors. 2. One promising finding is that a sizable majority of sellers have embraced sanitary practices such as cleaning carts, handwashing, and wearing masks. This demonstrates their commitment to customer safety and meeting the rising hygiene and sanitation expectations. This shift towards better hygienic practices is crucial for keeping client trust and loyalty following the pandemic. 3. The research also underlines consumers' fondness for Indian and Chinese street food. This information can help suppliers customize their menus to client demand and optimize their offerings. Furthermore, statistics reveal that street food vendors continue to be a popular option for late-night refreshments among customers. 4. Despite the positive developments, it is crucial to highlight the challenges that street food vendors have experienced during the pandemic. As a result of the limitations, lockdowns, and decreased foot traffic in urban areas, several vendors faced significant financial losses. Access to financial assistance and government assistance programs proved to be a significant impediment for many sellers, especially those operating illegally. It is vital to address and support these barriers to ensure street food vendors' resilience and sustainability. --- Recommendation: 1. Maintain and prioritize hygienic practices: Even after the pandemic, street food vendors should maintain and prioritize sanitary practices. Cart cleaning, handwashing, and the use of personal protective equipment should become standard practices to improve client safety and trust. --- Menu Diversification: To appeal to a wide range of consumer interests, merchants should consider diversifying their menu choices. This can increase revenue by attracting a broader customer base. 3. Digital Solution Adoption: According to the survey, many suppliers have yet to implement digital platforms for online ordering, delivery services, and contactless payment. Vendors should look into these options in order to improve client comfort and expand their reach. 4. Streamlining Financial Aid Obtain: Efforts should be made to make financial aid and government assistance programs more accessible to street food vendors. Clear information, fewer administrative hurdles, and reasonable documentation requirements can all help suppliers get the help they need during challenging times. --- Capacity Building and Training: Business management, financial literacy, and digital skills training programs and initiatives would assist vendors. These workshops can provide vendors with the knowledge and skills they need to adapt to changing conditions, expand their businesses, and improve their overall resilience. 6. Collaborations and Networks: Establishing collaborative networks among street food vendors, local governments, and key stakeholders can facilitate the exchange of best practices, expertise, and resources. This collaborative technique can help suppliers overcome obstacles, acquire support, and advocate for their common interests. 7. By putting these ideas into action, policymakers, local governments, and stakeholders may be able to reinvigorate and grow Kolkata's street food sellers, ensuring their long-term sustainability and preserving the city's particular street food culture.

The novel coronavirus disease outbreak (COVID-19) has had a severe impact on the street food industry, particularly in developing nations. This abstract explores the economic, social, and health-related implications of the pandemic on street food sellers. Economically, the methods taken to stop the virus' transmission have caused a sharp drop in consumer traffic, leading to lower income and financial instability. Socially, the pandemic has disrupted gatherings and communal meals, leading to contactless payment methods, online ordering, and delivery services, and rearranging their stalls to maintain physical distance. Finally, the effects of COVID-19 on health have been a major issue. For the proposed study, I have gathered 100 respondents from various areas of Kolkata, including Shyambazar, Howrah, Sealdah, Salt Lake, Sodepur, and Khardah. After gathering the data, I analyzed it with various statistical techniques and came to my conclusions. Street food vendors face a higher risk of catching the virus due to their profession, which involves handling food and having close contact with clients. They are now required to follow strict hygiene guidelines and have increased expenses and logistical difficulties. Despite these difficulties, street food vendors have proven their adaptability and perseverance. Governments and non-governmental organizations have offered support in the form of funding, educational opportunities, and policy changes. The main goals of initiatives to assist street food sellers should be to ensure their economic recovery, give them access to social and medical services, and encourage sustainable practices that put public health and livelihoods first.

Background In its Global Action Plan on Physical Activity 2018-2030, the World Health Organization identified a need for physical activity opportunities that use public spaces and engage whole communities [1]. Mass participation physical activity events have been recognised for their public health potential given their population reach, growing popularity and community context [2] and potential to engage patient populations [3]. However a criticism of mass sporting or physical activity events is that they can attract those who are already active and from more affluent areas [4,5]. 'One-off' mass participation physical activity or sporting events may also have limited potential to leverage sustained behaviour change [2]. Starting in London, United Kingdom in 2004, parkrun is a charity that organises free, weekly , timed 5 km mass participation events for people to participate as runners/walkers or volunteers . There is now a growing number of weekly parkrun events worldwide across 23 countries attracting millions of international participants and a global network of over 375,000 volunteers [6]. parkrun has been recognised in WHO's Global Action Plan as a working example of "regular mass-participation initiatives in public spaces, engaging whole communities, to provide free access to enjoyable and affordable, socially and culturally appropriate experiences of physical activity " [1]. parkrun events are organised by local volunteer teams and the opportunity to participate is open to all. Events are promoted as being inclusive to people from all backgrounds and abilities and research evidence would support its perceived inclusivity and ability to create a supportive environment [7][8][9][10][11]. Participation in parkrun is free: people register online and receive a unique 'barcode' containing their parkrun ID number that they take to any event across the world that is scanned and used to log attendance and completion time. An increasing proportion of events have been established in more socioeconomically disadvantaged areas in the UK, with higher population density resulting in better geographical access to events for those living in these areas [12,13]. Inequalities in registration and participation persist despite parkruns being located closer to more socioeconomically disadvantaged areas [12,14] with 13.1% of those participating at least once live in the most socioeconomically deprived areas of the UK . Previous research has demonstrated that individuals who live in socioeconomically deprived areas and are physically active may experience much better health and quality of life than their neighbours who are less active [15]. In a cohort study of 354 new parkrun participants in the UK, Stevinson and Hickson [16] also showed that parkrun participation is associated with significant positive changes in health and wellbeing over 6 and 12 months, including level of physical activity. However previous parkrun studies have not been designed to explore the relationship between socioeconomic deprivation and changes in physical activity for those inactive before participating and the perceived benefits of participation [16][17][18]. In 2018, a Health and Wellbeing Survey of UK parkrun participants was undertaken [19]. In this manuscript, we have used a large and diverse sample from that survey of parkrun runners/walkers and runners/walkers who volunteer to explore the following: Mean years registered with parkrun 3.5 Mean number of parkruns run/walked per year 3.7 1) the motivation for first participating in parkrun as a runner or walker; 2) the self-reported health and wellbeing benefits from participation in parkrun. We focus on sub-samples representing those who were previously inactive at registration, those from the most socioeconomically deprived areas, or both. --- Methods --- Procedure Ethical approval for the study was granted by Sheffield Hallam University Research Ethics Committee on 24/07/ 2018 and approval was granted from the parkrun Research Board. The study used an online survey, incorporating wherever possible existing measures used in health and wellbeing research. An advisory team, created using the parkrun Research Board and academics, were consulted to longlist and then shortlist the questions used in the survey. Each questionnaire or question was selected using the following criteria: relevance; validity; reliability; length; previous use. If suitable previous questionnaires or questions could not be identified, the research team developed study-specific questions to capture the outcome . The survey length and literacy were tested and re-tested via members of the research team and the advisory team. The reporting adheres to established standards for reporting internetbased surveys; The Checklist for Reporting Results of Internet E-Surveys [20]. --- Population and participants The sample was drawn from all parkrun registrants in the UK. Registrants received an email from parkrun containing a link to the survey. Survey participants had to be aged 16 or over and the survey was only available in online format and in the English language; there were no other explicit exclusion criteria. In this manuscript, we use the data from respondents who identified in the survey as runners/walkers and runners/walkers who also volunteer at parkrun. Runners/walkers are those who participate in parkrun by running or walking the 5 km course. Runners/walkers who also volunteer are those who participate in parkrun as a volunteer as well as a runner/walker. Findings relating to the health and wellbeing of parkrun volunteers and the perceived impact of volunteering at parkrun will be published separately. --- The survey The measures in the survey are described fully in Additional file 1 with a full copy of the survey, including wording for consent. The list below describes the subset of measures used in this study. --- Demographics Demographic data included date of birth, gender, ethnicity, employment, home parkrun , socioeconomic status and long-term health conditions. Socioeconomic status was assessed using index of multiple deprivation for Lower Level Super Output Areas derived from the postcode provided by the individual at parkrun registration. LSOAs are the smallest units from which Population Census data is compiled and onto which official data on socioeconomic context is mapped by the Office of National Statistics [21]. IMD scores were classified into four quartiles Q1 to Q4 where Q1 represented the most deprived areas. Long-term health conditions were recorded by selfreport using the question: "Are your day-to-day activities limited because of a health condition or disability which has lasted, or is expected to last, at least 12 months? Include conditions related to old age, sensory deficits, mobility problems, developmental conditions, learning impairments and mental health" followed by a list of health conditions if they answered 'yes, limited a lot' or 'yes, limited a little' . See Additional file 1 for the survey question. One question asked participants to state whether they most closely identified as a parkrun runner/walker, a parkrun runner/walker and volunteer or a parkrun volunteer. Respondents were asked to provide their parkrun ID number to enable their survey responses to be matched to the parkrun database that holds their parkrun registration details and participation information . See 'parkrun data' section below for more details. --- Life satisfaction and happiness Two of the four personal wellbeing questions asked in the UK's Office of National Statistics Annual Population Survey [22] were used as measures of life satisfaction and happiness: 1) "Overall, how satisfied are you with your life nowadays?" and 2) "Overall, how happy did you feel yesterday?" Statements were rated on a 10-point visual analogue scale where 0 is "not at all", and 10 is "completely". Life satisfaction and happiness were chosen from the four ONS measures because these aspects of wellbeing were not already captured in other measures used in the survey . Despite these ONS wellbeing measures being used extensively in large UK population surveys, there are no reported psychometric properties . Each answer is taken at face value and cut-offs determine high and low scores. --- Subjective health status Subjective health status was measured using the Euro-QoL visual analogue scale [23] which asks: "We would like to know how good or bad your health is TODAY. This scale is numbered from 0 to 100. 100 means the best health you can imagine. 0 means the worst health you can imagine. Please enter a number in the box below to indicate how your health is TODAY." The VAS was presented vertically with the label "the best/worst imaginable health" on the top/bottom and numbers ranging from 0 to 100 along the side. Permission was granted by EuroQol Research Foundation for its use. The construct validity of EQ-VAS has been reported as satisfactory [24]. Motivation for participating in parkrun as a runner/walker Motivation for participation in parkrun was measured with a question developed by the research team for the purpose of this study: "What motivated you to first participate at parkrun as a runner or walker?" Respondents were asked to select a maximum of three answers out of a possible 21 motives. Examples of motives included; "to improve my physical health", "to improve my mental health", "to manage my weight", "to improve my happiness", "to meet new people" and "to spend time with friends" . The 21 choices were displayed in randomised order to help reduce response bias. The final choice was "other" and, if selected, respondents were asked to specify the motive. Given that this was a study-specific question, there are no psychometric properties to report for this measure. --- Self-reported physical activity Self-reported physical activity was measured using three different measures: 1) a single item four-week recall physical activity question that is also asked at parkrun registration; 2) a single item 1 week recall physical activity question [25]; and 3) the International Physical Activity Questionnaire Short Form [26]. The four-week recall question asked: "Over the last 4 weeks, how often have you done at least 30 minutes of moderate exercise ?" Respondents could answer: less than once per week, about once per week, about twice per week, about three times per week, four or more times per week, rather not say, don't know. This question was chosen as it was also asked at parkrun registration, allowing direct comparison between pre-parkrun participation and post-parkrun participation. Given that this was a parkrun-specific question, there are no psychometric properties to report for this measure. This single-item physical activity measure was developed by Milton, Bull [25] and asks: "In the past week, on how many days have you done a total of 30 minutes or more of physical activity, which was enough to raise your breathing rate. This may include sport, exercise, and brisk walking or cycling for recreation or to get to and from places, but should not include housework or physical activity that may be part of your job." Respondents could answer: 0 days, 1 days, 2 days, 3 days, 4 days, 5 days, 6 days, 7 days. This has been validated against the Global Physical Activity Questionnaire in a UK sample of 240 adults [25]. Physical activity was also measured using the International Physical Activity Questionnaire short form [26]. The IPAQ-SF is a validated, subjective measure of physical activity [27] and was asked as an optional question at the end of the survey, to enable comparison across the different physical activity measures and to give additional insight into the intensity of activity being done. Respondents answered 7 questions on the frequency, intensity and duration of physical activity participation over the past 7 days. --- Perceived impact of running/walking at parkrun The perceived impact of parkrun was measured using a question developed by the research team for the purpose of this study: "Thinking about the impact of parkrun on your health and wellbeing, to what extent has running or walking at parkrun changed:" Respondents were presented with a list of 15 potential impacts and asked to rate each one on the following 5-point scale: much worse, worse, no impact, better, much better. Examples of impacts included: "your physical health", "your mental health", "your ability to manage your weight", "your happiness", "the number of new people you meet" and "the amount of time you spend with family" . The answer choices were displayed in randomised order to help reduce response bias. The final choice was "other" and, if selected, respondents were asked to specify the impact. Given that this was a study-specific question, there are no psychometric properties to report for this measure. --- Parkrun data Additional data was exported from the parkrun database when enough personal details were provided to enable data matching. Additional data matched to responses included the following: postcode provided at parkrun registration; date of parkrun registration; self-reported physical activity level at registration using the four-week recall question; and total number of parkruns completed since registration. --- Data collection Pilot testing was carried out on a randomly selected sample of 200 UK participants . Subsequent power calculations suggested that the survey would have to be sent to the full parkrun population to allow segmentation to a sub-sample from socioeconomically deprived areas and who were previously inactive at registration . The survey was distributed between 29th October and 3rd December 2018. The survey used Qualtrics online survey software [28]. The web link contained an introductory page with a participation information sheet and a confirmation box to indicate it had been read, understood and consent given to be part of the take part. Only people emailed the web link could access the survey. View rate of the survey was not captured. The survey was open for 5 weeks from 29th October 2018 with staggered sending of emails due to email server limitations. Reminders were emailed after 1 week. There were no incentives offered for taking part in the survey. Questions were asked in the order presented in Additional file 1, with the exception of the International Physical Activity Questionnaire Short Form , which was asked as a final, optional question due to its length and to keep it apart from the other physical activity measures used earlier in the survey. Questions were not randomised, but response choices within some questions were . Adaptive questioning was utilised, such that certain questions were displayed based on answers to previous questions. For example, people who reported being walkers/runners did not see questions about volunteering at parkrun. There was a maximum of 47 questions, with an average of 4.3 questions per page and a maximum number of 11 screens of questions . Questions were optional with the exception of the question about parkrun participation type , one question about long-term health conditions and two questions about life satisfaction and happiness. Respondents could go back and forth within the survey to review or change answers. Upon clicking 'submit', answers could not be changed. With consent, partially completed survey responses were saved and data kept for analysis unless the respondent requested removal by contacting the research team. --- Data handling Survey returns that included identifiers were matched, with consent, to parkrun registration data for 74% of survey respondents . All data was pseudonymised after matching with parkrun registration data. Data was handled in accordance with the Data Protection Act 2018 and the General Data Protection Regulation 2018. Data cleaning and analysis was carried out in Microsoft Excel, SPSS and MATLAB . Duplicate responses were identified by their unique Qualtrics code assigned during the survey and only the latest time-stamped response retained. Responses were excluded if they consented and filled out some or all demographic data but did not fill out any other survey questions to enable analysis. Six respondents were removed either due to abusive comments in free text, because of nonsensical responses, or both. Respondents were not obliged to answer all questions and partially completed surveys were included in the analysis, meaning the sample size varied across each analysis. Cases with missing data on certain variables were omitted from that specific analysis and we have reported the relevant sample sizes in all tables. --- Data analysis Descriptive statistics were used to characterise the respondents and compare them to the total population of parkrun registrants from which they were drawn. Subsample analyses where then undertaken to compare health and wellbeing, motivation for participation and self-reported benefits of participation between groups defined by socioeconomic deprivation status as well as their self-reported activity level at registration. Respondents from the most socioeconomically deprived areas are labelled 'deprived sub-sample' and those who self-reported as being the least active at parkrun registration are labelled 'inactive sub-sample'. Respondents from the most socioeconomically deprived areas and the least active at registration are labelled 'deprived/inactive sub-sample'. For descriptive statistics, we report percent, mean, median and interquartile range . Data such as age, happiness, life satisfaction, health today, parkruns per year, years registered with parkrun and the single physical activity question were non-parametric. Group comparisons were carried out using the Mann-Whitney U test. The alpha level used as the criterion for statistical significance in all inferential tests was p < 0.05 or lower. Effect sizes were calculated using Cohen's d using a pooled standard deviation with sizes defined as follows: small 0.10; medium 0.5; large 0.8; very large 1.2; huge 2.0. --- Results --- Survey responses The survey resulted in 100,864 respondents . The following were removed from the analysis: 1) respondents who did not consent ; 2) respondents who consented to view the survey but did not answer any questions ; 3) respondents who had registered with parkrun but not participated ; 4) respondents who identified as parkrun volunteers , i.e. were not runners or walkers; and 5) respondents who provided invalid responses [7]. The dataset used in this manuscript had 38,071 who identified as runners/walkers and 21,929 who identified as runners/ walkers who volunteer, giving a combined data set of 60,000 . --- Demographic characteristics of respondents Table 1 shows the characteristics of parkrun population from its inception on 2nd October 2004 to 3rd December 2018. The mean age was 40.5 years with 51.3% female; 181,561 or 13.1% were from the most deprived areas while 109,296 or 6.6% were previously inactive at registration. They had run or walked approximately 3.7 parkruns per year and been registered with parkrun for around 3.5 years. Table 2 shows that the deprived, inactive and deprived/inactive sub-samples had 4384, 2184 and 237 respondents respectively. The proportion of the full sample who were female was 51.7% ; this increased in the deprived, inactive and deprived/inactive sub-samples to 52.5, 54.8 and 56.1% respectively. The mean age of the full survey sample was older than the parkrun population . Mean age decreased for the deprived, inactive and deprived/inactive sub-samples to 44.3 ± 12.7, 45.6 ± 12.6 and 43.6 ± 12.0 years respectively . The full sample was 96.4% White with 2.9% from a Black, Asian or other ethnic background; the latter increased for the sub-samples to 6.0% for the deprived/inactive sub-sample. 55.7% of the full sample were in full-time employment with an additional 14.0% part-time and 9.5% self-employed; 12.5% were retired, 3.1% were students and 1.2% were unemployed. The proportion in the sub-samples who were retired decreased while those who were unemployed increased . Table 2 shows values for happiness, life satisfaction and health for the full sample and sub-samples. Those in the deprived sub-sample reported 2.3% lower happiness than the full sample and 2.3% less life satisfaction . This reduction increased for the inactive sub-sample to 3.3% for happiness and 3.5% for life satisfaction . The deprived/inactive sub-sample reported 5.3% less happiness and 4.5% less life satisfaction than the full sample . It should be noted that the sample size was small in the latter group . In England and Wales, national happiness has been reported as 7.53 out of 10 and life satisfaction 7.69 out of 10 [22]. In terms of overall health as measured by the EQ-VAS, those in the deprived sub-sample reported 2.1% lower health scores than the full sample ; those in the inactive sub-sample reported 4.6% lower health scores and the deprived/inactive sub-sample reported the greatest reduction at 7.8% compared to the full sample. It should be noted that there were only 225 respondents in the deprived/inactive sub-group. --- Motives for participating in parkrun Respondents to the survey were asked to select three motives for initially taking part in parkrun: the results are shown in Table 2. The first and second most reported motives for the full sample were 'to contribute to my fitness' and 'to improve my physical health' . The proportions choosing fitness tended to decrease for the deprived and inactive sub-samples, while the proportions choosing physical health tended to increase. The rankings reversed for the deprived/inactive subsample, so that 'to improve my physical health' was the first-ranked motive while 'to contribute to my fitness' was the second . The motive 'to gain a sense of personal achievement' was ranked third in the full sample and had a similar proportion of respondents across the sub-samples . The fourth ranked motive in the full sample was 'to get a recorded time for a 5k' at 21.4%; this reduced to 11.7% for the inactive sub-sample and to 12.8% for the deprived/inactive sub-sample so that it was ranked seventh place. In contrast, the fifth ranked motive for the full sample was 'to manage my weight' ; this moved up to third place for the inactive and deprived/inactive sub-samples . --- Participation and physical activity levels Table 2 shows the frequency of participation in parkrun. The full sample was registered for 3.13 ± 2.53 years; all sub-samples were registered more recently than the full sample with the deprived/inactive sub-sample registered for 2.28 ± 1.80 years . The total number of parkruns run or walked was highly skewed with the full sample doing a mean of 46.0 ± 61.1 parkruns and median of 21 parkruns. The sub-samples completed fewer parkruns with the deprived/inactive sub-group doing least . The mean number of parkruns per year run or walked by the full sample was 14.6 ± 12.2 and, although the deprived and inactive sub-samples were statistically different , the effect sizes were small . Comparison of the parkrun physical activity question asked at the survey compared to that asked at parkrun registration showed that 88.2% of the inactive sub-sample reported an increase in their activity level following parkrun participation. A similar increase of 86.5% was found for the deprived/inactive subsample. The median number of days of activity for this previously inactive group had increased to 2 days of activity per week. Table 2 shows findings from the single-item physical activity measure developed by Milton, Bull [24]. The full sample reported doing 3.59 ± 1.77 days of activity per week, while those in the inactive sub-sample reported 2.41 ± 1.67 days per week. Those in the deprived/inactive sub-sample reported a similar value of 2.47 ± 1.71 days of activity. The IPAQ-SF results indicated that 37.8% of the inactive sub-sample and 40.4% of the deprived/inactive sub-sample did physical activity that was vigorous enough to be health enhancing, according to the scoring system provided by IPAQ-SF [26]. --- Perceived impact of running or walking at parkrun The reported benefits for the sub-samples are compared with the full sample in Table 3: response counts are shown in the table. All respondents tended to select no impact, better or much better for the 15 perceived impacts of parkrun. The proportion selecting worse or much worse was on average 0.5% for the 15 impacts, apart from 'the amount of time spent with family' at 6.2%. Mann-Whitney test between full sample and sub-samples: x p < 0.05; y p < 0.01; z p < 0.001 Effect size was calculated using Cohen's d using a pooled standard deviation. Effects are defined as follows: small 0.10; medium 0.5; large 0.8; very large 1.2; huge 2.0 Table 3 shows the proportions of respondents reporting only improvements to the measures since participating in parkrun, i.e. a combined value of those reporting 'better' and 'much better'. The data for the full sample shows that, 'sense of personal achievement' had the largest proportion of 90.7%. The second highest rated measure was fitness followed by physical health , happiness and the amount of time spent outdoors . Mental health was improved for 69.3% of respondents and 'overall lifestyle choices' improved for 51.8%. The proportion reporting improvements on the perceived impacts tended to be higher for the deprived subsample, higher again for the inactive sub-sample and highest for the deprived/inactive sub-sample. A notable exception to this was 'enjoyment of competing' where the proportion decreased from 72.7% for the full sample to 70.6% for the inactive sub-sample and 70.1% for the deprived/inactive sub-sample. --- Discussion In this self-selected sample of parkrun participants, all respondents, irrespective of demographic characteristics and socioeconomic deprivations status, reported diverse benefits from participation in parkrun as runners/walkers. Whilst there was response bias in favour of those participating in parkrun more frequently, and fewer responses from those from more socioeconomically deprived areas and less active at registration, the scale of the survey ensured that comparison of these sub-groups with the sample as a whole was possible. We were able, for the first time, to compare benefits in those groups who have the greatest theoretical capacity to benefit from participation in parkrun with other sub-groups from within the parkrun population. This addresses a key priority linked to the achievement of population goals identified in the WHO's Global Action Plan on Physical Activity [1]. When compared to the full sample, the deprived, inactive and deprived/inactive sub-samples had a larger proportion of females, were younger, less likely to be retired and more likely to be unemployed; they were also more likely to be from a Black, Asian or other ethnic minority background and more likely to report having long-term health conditions. These factors could contribute to the lower happiness, life satisfaction and health score for the sub-samples, which warrants further investigation, especially as more of the deprived and inactive sub-groups reported improvements to health and wellbeing impacts due to parkrun compared to the full sample. The parkrun participants in our survey who were previously inactive reported an increase in their activity levels from doing less than 1 day of activity per week at registration, to doing on average 2.4 days per week. Thus, in addition to the 15 or so parkruns completed per year on average, this would equate to another 111 days per year of physical activity outside parkrun; this increases to 115 days per year if they are also from more deprived areas. If the reported increases in physical activity observed here were to be replicated in the full parkrun population, then this could have substantial public health value. Given that individuals living in more socioeconomically deprived areas who are physically active may experience better health and quality of life than their neighbours who are less active [15], further research is needed to explore how community physical activity initiatives like parkrun can use strategies that promote inclusivity and encourage better representation from currently underrepresented populations. Whilst the range and magnitude of benefits reported in this study indicate that respondents from across all sub-groups believe running or walking at parkrun impacted positively on their health and wellbeing, more of those who were from the most socioeconomically deprived areas, and those least active at registration, reported greater improvements than the full sample. Despite this, their self-reported health and wellbeing was consistently lower than the full sample, reflecting persistent and widely recognised health inequalities. --- Further research to explore factors related to benefits from participation There is a growing body of qualitative research exploring the motivations for participation in parkrun and the positive benefits experienced by those who attend [7-9, 29, 30]. Research has also explored the barriers to participation for specific communities and population groups and the potential for action research in Table 3 Perceived impact of running or walking at parkrun using the question "Thinking about the impact of parkrun on your health and wellbeing, to what extent has running or walking at parkrun changed:" Allowed responses were 'much worse, worse, no impact, better, much better'. Proportions are a combined value of 'better' and 'much better' developing inclusive strategies to increase participation by underrepresented groups [11]. Valuable insights could be gleaned from understanding the barriers to participation in community initiatives like parkrun among people from more inactive groups, including those from socioeconomically deprived areas. Such research would help build a more nuanced understanding of the factors that underpin participation. Working with communities to understand these challenges is an important step in designing inclusive strategies to promote participation that could potentially translate into important health benefits and contribute to reducing health inequalities. Further analysis of matched parkrun data, using recorded parkrun participation as well as survey responses, could be used to explore the complex and bi-directional relationship between frequency of participation and changes in health and fitness and reported benefits. These relationships may vary for different types of benefit, with some benefits being experienced at lower levels of engagement and frequency of participation than others. It is also likely that overall perceived benefits may be related to the original motivation for participation. The benefits related to volunteering at parkrun, as well as those related to running and walking should also be explored, as there is substantial evidence from previous research that there can be direct and substantial health and wellbeing benefits from volunteering, such as positive impacts on mental and physical health, life satisfaction, social well-being and depression [31]. The potential impact of parkrun volunteering, compared to running/walking at parkrun, is being explored by the authors separately. There is also potential for parkrun and similar community-based events to address current inequalities in both volunteering opportunities and the related benefits [32]. The overall benefits to a community are likely to be much greater than the sum of the benefits reported by individual participants. Wider benefits may include improved perceptions of the local area, increased economic activity if participants use local cafes and shops when attending an event [30], community spirit [29,33] and linking stakeholders within a community, as seen in the UK's parkrun practice initiative [34]. Previous researchers have used a Social Return of Investment methodology to quantify the wider benefits due to sport [35]. A similar analysis of parkrun would allow potential funders, local authorities and those wishing to set up similar interventions to understand their social impact and return on investment. --- Implications for policy and practice The example of parkrun shows that large-scale, mass participation physical activity initiatives could impact positively on the health and wellbeing of participants and have the potential to address health inequalities. It has been assumed that the population groups with lowest levels of physical activity and highest risk of the associated chronic health conditions, who are also more likely to live in more socioeconomically deprived areas, potentially have the most to gain from being more active. However inequalities in personal and environmental resources, including access to transport and free time for recreation at weekends, and other social and cultural barriers to attendance, are reflected in disparities in health behaviours [36]. In terms of motives, the results of this study imply that those from socioeconomically deprived areas, who were previously inactive, or both are more motivated by their health and improving their lifestyle than fitness, competition or training for other events. parkrun and other organisations might consider these factors when starting new community events. This study shows that if these population groups do participate in recreational physical activity, they do report the highest levels of benefits. Further research is needed into the barriers experienced by people who theoretically have the most to gain from participation. --- Strengths and limitations The major strength of this study is the size and diversity of the dataset that ensured that, despite the low response rate and response bias expected for an email based online survey [20], the sample had the statistical power to explore variation between sub-groups of participants including those underrepresented in previous research i.e. those least active at registration and those living in the most socioeconomically deprived areas of the UK. The findings should be interpreted in light of further methodological considerations. The cross-sectional nature of the data means the associations observed cannot be inferred as causal; many influential factors outside of parkrun may have contributed to the positive changes observed. Longitudinal studies are needed to explore how parkrun and health and wellbeing interact over time. The findings should be interpreted with small subsample sizes in mind, especially the deprived/inactive subsample. The socioeconomic deprivation status of respondents was not studied directly through questions about employment, income etc., but was inferred from IMD derived by the postcode provided at parkrun registration. This gave a proxy socioeconomic status measure for the area lived in when the respondent first registered with parkrun, rather than specific to the respondent at the time of survey completion. The survey was only available in online format in the English language which may potentially exclude people who had limited internet access or low literacy and digital literacy levels. Future implementation of this survey would benefit from designing, testing and piloting the survey with members of the public, especially those representing underrepresented groups such as people from Black, Asian and other ethnic minority backgrounds and those from areas of higher socioeconomic deprivation. A further aspect of the survey design worthy of consideration is that a combination of pre-existing, validated survey questions and study-specific questions derived by the research team were used. This was deemed a pragmatic decision to ensure that responses were relevant to parkrun participation, but introduces some inconsistency to the methods and potential bias to the findings. Response bias could also be assessed from the matching of survey responses to parkrun registration data available for the full sample. This indicates that the main difference between respondents and parkrun participants invited to complete the survey is in the number of parkrun events attended . The results therefore relate to a sample that attend parkrun more often and that in addition may well have experienced higher levels of perceived benefit, leading in turn to both more frequent attendance and greater motivation to complete a questionnaire on their health and wellbeing in relation to parkrun participation. Given this, we also undertook an analysis of a truncated sub-sample that was more representative of the parkrun participant population where the mean was 3.7 parkruns per year . Even in this truncated sample, the benefits of parkrun to respondents were similar to the full sample. --- Conclusions Survey respondents, representing parkrun participants with a diverse range of demographic and socioeconomic characteristics and of physical activity levels at parkrun registration, reported a wide range of benefits that they credited to parkrun participation. Around 9 out of 10 of those who were previously inactive reported increases to their physical activity and similar proportions reported improvements to their physical health and fitness. This proportion increased further for those from socioeconomically deprived areas. The results show that parkrun and similar initiatives can introduce large numbers of people from diverse backgrounds to recreational physical activity and impact positively on a high proportion of them. It is important that future research helps identify how community initiatives like parkrun can better engage with those groups who potentially have most to gain from being more active in order to maximise impact. --- --- Abbreviations EQ-5D: EuroQol; EQ-VAS: EuroQol Visual Analogue Scale; IMD: Index of Multiple Deprivation; IPAQ-SF: International Physical Activity Questionnaire Short Form; LSOA: Lower Level Super Output Area; UK: United Kingdom; WHO: World Health Organization --- --- --- --- Consent for publication Not applicable. Competing interests AB, CW, CS, EG, HQ, LR, MG, RC, SH are all parkrun registrants, but did not complete the survey. All authors were members of the parkrun Research Board based at the Advanced Wellbeing Research Centre at Sheffield Hallam University at the time of writing this paper. SH is the Chair of the parkrun Research Board. CW and MG are employees at parkrun. Parkrun commissioned Sheffield Hallam University to conduct this survey. CW and MG were involved in design of the study and matching data to the parkrun database, they approved the final manuscript. All other authors declare that they have no other competing interests. ---

Background: Whilst the benefits of physical activity for health and wellbeing are recognised, population levels of activity remain low. Significant inequalities exist, with socioeconomically disadvantaged populations being less physically active and less likely to participate in community events. We investigated the perceived benefits from participation in a weekly running/walking event called parkrun by those living in the most socioeconomically deprived areas and doing the least physical activity. Methods: A cross-sectional online survey was emailed to 2,318,135 parkrun participants in the UK. Demographic and self-reported data was collected on life satisfaction, happiness, health status, physical activity, motives, and the perceived benefits of parkrun. Motivation, health status and benefits were compared for sub-groups defined by physical activity level at parkrun registration and residential Index of Multiple Deprivation. Results: 60,000 completed surveys were received (2.7% of those contacted). Respondents were more recently registered with parkrun (3.1 v. 3.5 years) than the parkrun population and had a higher frequency of parkrun participation (14.5 v. 3.7 parkruns per year). Those inactive at registration and from deprived areas reported lower happiness, lower life satisfaction and poorer health compared to the full sample. They were more likely to want to improve their physical health, rather than get fit or for competition. Of those reporting less than one bout of activity per week at registration, 88% (87% in the most deprived areas) increased their physical activity level and 52% (65% in the most deprived areas) reported improvements to overall health behaviours. When compared to the full sample, a greater proportion of previously inactive respondents from the most deprived areas reported improvements to fitness (92% v. 89%), physical health (90% v. 85%), happiness (84% v. 79%) and mental health (76% v. 69%).

Riedl 2019 ). However, a lack of agreement concerning the elements of news media quality also exists among these scholars. Dimensions of news media quality include, among others, acceptance, actuality, balance, clarity, completeness, detachment, diversity, factuality, impartiality, lawfulness, neutrality, objectivity, professionalism, relevance, and truth . As a result, the construct of "media quality" is elusive, as McQuail states, "There are simply no universal evaluative criteria to hand and many of those chosen often owe their relevance to change and passing circumstances of time or place" . Empirical research on media quality splits into at least two strands, each strand with many ramifications. Surveys are used to assess audiences' expectations and perceptions regarding media quality and related constructs , particularly trust and credibility , and perceived news media importance . In this research strand, much effort has been devoted to scale development and validation . Contrastingly, content analysis is used to assess media quality from a content perspective. This research strand focuses on certain media types , especially newspapers and news websites or certain aspects of content quality, such as the decline of hard news in newspapers , the supply of political information or deliberativeness in television programs , or the diversity of news reporting . Only a few studies combine the two strands , allowing illumination of the relationship between the audience and content perspective. Summing up, the conceptual literature reflects on the many facets of news media quality to the detriment of operationalizability and measurability, while the empirical analyses obtain great precision by focusing on specific media types or using specific indicators , but tend to neglect theoretical considerations. So far, no study has evaluated the news media quality of all news media outlets of different types in a media system from both an audience and a content perspective based on a holistic definition that includes the construct's different dimensions. This conceptual and methodological paper therefore attempts to synthesize conceptual and empirical research into a holistic approach that allows analyses across types and media systems. --- Toward a Postpositivist Definition of News Media Quality --- Double Hermeneutic in News Media Quality Research Giddens' notion of the double hermeneutic can explain why, despite decades of research, it has not been possible to obtain a single binding definition, operationalization, and measurement regarding news media quality. Giddens' ) postpositivist theory states a fundamental difference between social science and natural science. While natural science deals with an external matter, social science is about investigating phenomena-including news media quality-that are already interpreted in society in a myriad of ways. Hence, in social science, it is impossible to get single binding and universally accepted definitions for two intertwined reasons. For one, social scientists interpret preinterpreted phenomena. Giddens speaks in this respect of the "second-order" knowledge of social scientists, which is about the "first-order" knowledge of people. Second, social scientific interpretations that enter public discourse modify peoples' interpretations, whereby in turn, the initial subject matter is changed. This is what Giddens calls the "double hermeneutic," which is unique to social science . Regarding news media quality, the understandings developed by scientists and empirical research became part of the public discourse about media quality and media policy documents , thus altering the very matter they attempt to define. Acknowledging the double hermeneutic, social scientists should consider their role in the construct's dynamic, contingent, and contested character and aim for definitions, operationalizations, and measurements that are open to scrutiny, reinterpretation, and redevelopment. We therefore attempt to first explore the utmost boundaries of how news media quality can be understood in a meaningful way, before proposing our own definition of news media quality rooted in Habermas' ideal of deliberative democracy. --- Definitional Boundaries of News Media Quality News media quality is a specific type of quality. To explore the definitional boundaries of the term news media quality, we thus need to begin with disambiguation of the term "quality." The Oxford Living English Dictionary provides two definitions of quality: "The standard of something as measured against other things of a similar kind" and "the degree of excellence of something." These complementary definitions show that quality, and thus news media quality , is a relational construct. We can, therefore, identify at least four elements, which we label object , ideal , class , and criteria . These four elements, anchored in the perspective of double hermeneutics, enables us to structure different understandings of news media quality. From a research perspective, we begin with the question of which object is meant when speaking of news media quality. In academic literature, the scope of objects ranges from media systems or organizations to news media outlets and their contents, media types, programs, channels, news articles, and broadcast items : 279). The object is related to the class. A media system can only be assessed, at least meaningfully, against other media systems , a media organization only against other media organizations , a news media outlet only against other news media outlets , and so forth. Regarding the ideal, the question arises regarding from which normative perspective news media quality is assessed. In the most general sense, news media should contribute to a better society. Some authors speak of "public value" in this context . Since the understanding of news media quality is, in most cases, rooted in democratic theory, many scientists see the ideal of "good" media quality in its contribution to a functioning, vibrant democratic society . There are, of course, different normative ideal models of democracy, principally the liberal, representative, deliberative, and participatory model . As a consequence, numerous scientists involved in the study of media quality "have outlined the conceptual difficulties of applying one standard of excellence to all news markets" . This leads to many criteria for assessing news media quality. Urban and Schweiger note that German scholars have researched this matter intensively . Following a liberal tradition of democracy, for example, Schatz and Schulz discussed a set of quality criteria for television programs derived from legal and regulatory documents. Maurer considered the following criteria: actuality, balance, clarity, completeness, diversity, factuality, impartiality, neutrality, objectivity, professionalism, relevance, and truth. Hanitzsch et al.'s comparative study shows that "journalists across the globe pay high regard to the normative ideals of detachment, providing political information, and acting as a watchdog of the government" . The list of relevant quality criteria can be extended further. Arnold , Bosshart andHellmüller , andHolbert et al. , to name a few, pointed out that news media should also be entertaining and enjoyable, because entertaining news may provoke engagement with matters of general interest among citizens. This review, based on the four elements of quality, allows us to define the boundaries of news media quality, what it means in the most general sense: A media entity's journalistic content is superior or inferior in contributing to a better society in comparison with media entities of a similar kind as measured by specific normative dimensions . --- News Media Quality From a Deliberative Perspective The above-mentioned fourfold definitional scheme is too general to operationalize and measure news media quality in a concrete social context. Therefore, in a next step, we elaborate our understanding of news media quality by narrowing the definitional boundaries based on the four elements: object, ideal, class, and criteria. Our definition is postpositivist in the sense that we make its contingency transparent-other scholars may draw the boundaries differently. Our social scientific perspective is based on the theory of deliberative democracy from Habermas , as outlined in his talk "Political Communication in Media Society" and its further elaboration in the German language . By using the theory of deliberative democracy, we also acknowledge the presence of the double hermeneutic because Habermas' ideals regarding news media became part of the public discourse as well as media policy documents. Referring to Habermas , the ideal model of deliberative democracy "expects the political public sphere to ensure the formation of a plurality of considered public opinions" . To assure this, the news media system should be self-regulated. It should, as much as possible, be independent of political and economic control in order to reflect informed elite discourses and the views of a responsive civil society . A deliberative democracy requires reasonbased journalistic contents, promoted by news media outlets . Therefore, we consider general-interest news media outlets and their contents as the object of news media quality. Regarding deliberative impact, it must be assumed that different classes of news media outlets show considerable differences. Although commercial television and tabloid newspapers reach larger audiences than prestigious newspapers and magazines, the opinion leadership of news media quality is influenced by an "informal hierarchy" : 175). The informal hierarchy is based on criteria, which can be described as "discourse value factors" . According to our deliberative understanding, journalistic contents should be relevant, meaning they are produced, selected, and distributed according to the principles of "general before particular topics" and "public before private contents." In other words, hard news over soft news, where hard news can be defined as reports on politics, business, science, technology and related topics, and soft news as reports on celebrities, human interests, sports, and related topics . Journalistic contents should further be contextualized because public discourse benefits from news media that do not merely report but place information in a larger societal or political context. Besides providing facts, news media should explain and contextualize events. The content production should meet professional journalistic standards, such as pursuing objectivity, transparency, and verification. Lastly, content should be diverse, because without a variety of actors, topics, and opinions, the best argument is unlikely to evolve and prevail. Summing up, by linking the notion of the double hermeneutic, the four elements of quality, and Habermas' ideal of deliberative democracy, we outline our understanding of news media quality as follows. From a social scientific perspective, we assess news media quality by how well they foster public deliberation and strengthen the processes of democratic opinion-formation and decision-making. In this respect, news media quality means a news media outlet and its journalistic content is superior or inferior in fostering a political public sphere that ensures the formation of a plurality of considered, reason-based public opinions compared with other news media outlets as assessed in terms of relevance, contextualization, professionalism, and diversity . --- Multimethod Design and Procedure Our understanding of news media quality, outlined above, enabled us to develop and operationalize content analysis coding schemes and questionnaire items to measure news media quality from an audience perspective. --- Switzerland's Media System as a Showcase What is the situation regarding news media quality in Switzerland? Switzerland is a consensus democracy with direct democratic elements, a fragmented political party system, four official languages, and strong federalism with many semi-professional and part-time politicians. Direct democracy, with its potential for popular initiatives and referendums, requires a strong respect for minorities, and the formation of a plurality of considered public opinions is seen as essential in Switzerland . Accordingly, the ideal of deliberation is particularly relevant in Switzerland. The object of our research is general-interest news media outlets reaching at least 0.5 percent of the resident population in either the German-speaking or French-speaking parts of Switzerland. The news media outlets encompass classes of news media, such as daily and online newspapers, Sunday newspapers and weekly news magazines, tabloid and commuter newspapers, and public and commercial radio and television programs. The basic population for content analysis comprises all editorial news items in a year. Due to the large population size this yields, a sample is drawn in the form of a typical week for each news media outlet . The coding unit differs according to the type of media, such as articles from printed newspapers and magazines, online items from news websites, and broadcast items from radio and television news programs. The survey's basic population is the language-assimilated resident population in the French-and German-speaking parts of Switzerland. Therefore, the online questionnaire is available in both languages. Although an online sample is not fully representative, it can be noted that over 90 percent of the adult Swiss population today has an internet connection . --- Operationalizing the Four Criteria We examine the quality of Switzerland's news media outlets by analyzing their journalistic contents based on the four criteria derived from deliberative theory. The scale ranges from 0 to 10 . Moreover, we measure the quality of news media outlets as perceived by the Swiss audience. Since existing scales either reflect different dimensions of news media quality or measure related constructs such as credibility , trust , or quality expectations , we derived new questionnaire items regarding each of the four criteria. The items were reviewed with external experts and media practitioners from both French and German languages for relevance and comprehensibility. The respondents' evaluations of the news media items were assessed on a five-point Likert scale, ranging from low to high . Relevance. Relevance refers to the ideal that general issues should take precedence over particular issues and societal issues over private ones. Relevance comprises the dimensions topic relevance and actor relevance. A news item has the highest topic relevance if it is about politics . A very high score is also reached if topics in the socially highly relevant spheres of economics or culture are covered. Lower scores are coded if a news item is about sports or human interest because they are less relevant in democratic opinion-formation processes. Since sports can contribute to the integration and cohesion of a society, this topic area is scored slightly higher than that of human interest. A news item scores highest in the actor relevance dimension if it is about society as a whole or its functional systems and highly if it is about organizations or institutions . Contrastingly, a news item scores lower on actor relevance if it is about individuals in their functional roles and lowest when the coverage is solely about private aspects of a person . The news media outlet's relevance score is calculated as an index of topic and actor relevance, which considers that the two dimensions are not intended to compensate for each other. For example, a news item on politics which represents private aspects of a politician receives a low relevance score and not an average value of 5.5. All scores are also transformed in such a way that they again range from 0 to 10. For multiplicative indices, this is achieved by dividing the scores by 10: Relevance score = topic relevance × actor relevance 10 Regarding the survey, the perceived relevance of news outlets was measured with three items that reflect the dimension of actor or topic relevance: The news media outlet "… focuses on socially relevant topics in their report,""…reports about relevant societal processes rather than about individuals," and "… concentrates on important occurrences rather than featuring miscellany." Contextualization. News media should go beyond mere reporting of single events. We distinguish two dimensions of contextualization. First, news media content should embed events in longer-term developments and contexts, that is, provide the audience with sufficient background information . Second, news media should also be a source of orientation by providing interpretations . Regarding the variable thematic orientation and relying on Iyengar's dichotomy of thematic and episodic reporting, a news item which makes a so-called thematic classification of the reported events, for example, embeds events in cause-effect relationships, is of high value . Contrastingly, a so-called episodic news item, which only reports singular events without embedding them in context, is of lower quality . The dimension interpretative performance starts with the news genre and measures how much the news item contributes to building opinions. News stories and reportage where the focus is on research, interpretative presentation, and analysis, and opinion-oriented formats such as commentaries or editorials, where subjective points of view are presented and justified, both support the democratic opinion-formation process and receive a high score . Interviews , and news reports also contribute to understanding the interpretations and opinions of those actors in a news item. Finally, a news item shows a low level of interpretation if it contains external material which is only partially edited or consists entirely of external content such as agency copy . Concerning the content analysis, the score regarding the quality dimension of contextualization is calculated as an additive index from the variables thematic orientation and interpretative performance. When combining these two indicators, we give a slightly higher weight to the variable thematic orientation, since this variable reflects even more the investment of journalists in investigative reporting. The additive index considers that the two variables complement and compensate each other: Contextualization score = + Regarding the survey, the perceived contextualization of a news media outlet was measured with four items that reflect thematic orientation and interpretative performance: "picks up on socially relevant topics early on,""gives extensive background information,"" places occurrences within a wider context," and "presents substantial background information about current topics." Professionalism. The criterion of professionalism refers to socially and democratically founded quality standards rooted in the self-image of professional information journalism. The variables objectivity, source transparency, and independent reporting serve as indicators by which the professionalism of reporting is analytically measured. The dimension objectivity captures a news item's dominant style of argumentation. A news item in the cognitive-normative style corresponds to an important measure of deliberative democracy theory in that arguments must be objectively weighed against each other. Such a news item is scored accordingly high . Contrastingly, moral-emotional messages focusing on emotions that are detrimental to a rational discourse, or written in the form of polemics and thus distracting from civil and respectful dialogue, are classified as low . The source transparency dimension refers to journalism's professional requirement to disclose the sources that will be used for news items. Source transparency is credited when the news item's source is clearly indicated, be it with author name, abbreviation, or reference to a news agency . News items lacking these transparent indications do not meet the requirements for source transparency and are, accordingly, scored low . Finally, the variable independent reporting gives a higher rating of media quality if the reporting focuses little on external services such as agency copy. Journalism can only fulfill its democratic functions if it proves to be independent of the external services of communicative suppliers. The highest score is assigned to coverage from in-house correspondents, who represent an indispensable prerequisite for the independent processing of different geographical regions . Reporting by staff members also indicates a high level of journalistic input. Texts by guest authors or external experts and news items produced in cross-title editorial cooperation receive medium quality scores . Finally, news items that are only partially edited by staff members based on external material receive a lower score , as do news items based entirely on external services such as agency copy . The score of the quality dimension professionalism is calculated as the multiplicative index of the variable objectivity and the additive index of source transparency and independent reporting. This method considers that source transparency and independent reporting are regarded as complementary variables, while objectivity is regarded as noncompensatory to the other two variables. This means a news item of low cognitive-argumentative value should, in any case, be scored low, even if the source is transparent and the news item is produced by a staff member: Professionalism score = Objectivity × / 2) 10 Regarding the survey, the perceived professionalism of a news media outlet was measured with four items that reflect objectivity, source transparency, and independent reporting: "stands for independent reporting,"" clearly distinguishes between news and opinions,""focuses on arguments over emotions in their coverage," and "presents their news sources transparently." Diversity. In contrast to the three quality dimensions of relevance, contextualization, and professionalism, whose indicators are measured at the news item level, the quality dimension diversity is determined as a distribution measure at the overall reporting level of a media outlet. Diversity is therefore a quality dimension that does not appear in every news item, but in the sum of all news items of a specific media outlet. The indicators used to measure the diversity of a media outlet are content diversity and geographical diversity. Content diversity relies on codes at the level of news items. It is formed through category combinations of the variables topic relevance, actor relevance, and contextualization . To quantify the quality of content diversity, we determine a reference distribution, which should reflect an ideal normative distribution but also be an empirical-realistic target that a news media outlet can actually achieve. We define a balanced ideal distribution, which assigns a weight of 12.5 percent to each of the eight categories . In line with deliberative theory, we give higher weight to the area of politics in terms of content diversity. This is manifested in four versions of politics, which are to be covered in a balanced way, that is, 12.5 percent each. Due to the central importance of the topic of economics, we also give this area a high weighting and assign two categories to it, which should be covered in a balanced way, that is, 12.5 percent each. The areas of culture and human interest are also ideally weighted at 12.5 percent each. Our scoring thus considers human interest content as a legitimate subject area for reporting. The normative consideration behind this is that journalistic media should attract the attention of the public, for which human interest content is essential. However, human interest content should not take over in reporting. The comparison with the actual distribution we find for the coded news items in 2017 shows indeed that the actual weight of the sport/ human interest in our sample category is significantly higher compared to the ideal distribution . The second diversity indicator, geographical diversity, measures the extent to which a news media outlet covers different geographical reference areas. A distinction is made between the characteristic values: local/regional, Switzerland national/ Switzerland bilateral, foreign country, and multinational. Our analysis had to make media with very different journalistic orientations comparable. Since not all of the examined news media outlets have local coverage , but all of the examined media should also be made comparable in terms of this quality dimension, we excluded local coverage from the assessment of geographical diversity. The geographical diversity indicator thus measures the convergence towards a balanced coverage of the three geographical characteristics: national/bilateral, foreign, and multinational. In the balanced ideal distribution, the three characteristics each receive a weight of 33.3 percent. In accordance with the theory of democracy, we postulate that the media should report in a balanced way on events at these different geographical levels of reference. The quantification of both diversity indicators is based on the Shannon index formula for measuring diversity . The shares of the category combinations are multiplied with their natural logarithms, summed up, and put into proportion with the logarithm of the number of proportional values , who examine different diversity measures). Diversity for both indicators, that is, content and geographical diversity, is thus calculated according to the following formula, where i is the number of category combinations of diversity : H = i share i × lnln share i lnln i 2 × 10 An ideal distribution results in an index value of ten for both diversity indicators, which means maximum diversity across the eight or three characteristics analyzed. The combined score of the quality dimension diversity is then calculated as a multiplicative index of the diversity of content and geography: Diversity score = Diversity of content × geographical diversity 10 Regarding the survey, the perceived diversity of a news media outlet was measured with four items that focus on content diversity: "offers a complete overview of all the important events,"" covers various perspectives in its reporting,"" reports about various different topics," and "conveys diverse perspectives and opinions." The survey therefore did not specifically differentiate between content and geographical diversity. However, the indicator items for diversity have been set up so diversity assessments regarding content and geography are also implied. Subsequently, we calculated a mean score for each article or broadcast item based on the scores for each criterion. An article's number of words or a broadcast item's duration was used as a weighting factor to consider whether or not more extensive items contribute more to a news media outlet's overall quality. --- Data Collection and Sample Sizes The Swiss news media outlets with the farthest reach-including printed and online newspapers, tabloids, magazines, and broadcast programs-were examined in two stages. In the first round, fifty news media outlets were included. The content analysis comprised 20,931 news articles or broadcast items published or aired in 2017. The corresponding representative online survey was distributed in spring 2018. Since respondents can only evaluate the quality of news media outlets that are familiar to them, each respondent was initially assessed on how well they knew randomly selected news media outlets, with options ranging from 1 to 5 . Subsequently, the respondents were asked in detail about no more than seven news media outlets they knew well or very well . A total of 13,321 news media outlet assessments were obtained from 2,169 respondents. The second round was conducted in the same way. This time, only forty-nine news media outlets were examined, because one news media outlet was stopped in 2019. This analysis comprised 18,559 news articles or broadcast items published or aired in 2019; 11,480 assessments were obtained from 2,159 respondents to an online survey distributed in spring 2020. --- Scoring News Media Quality From Both Perspectives We examined the four quality criteria to create an overall news media quality score for the two perspectives to analyze and compare the findings of the content analysis and the representative survey. We conducted regular meetings with the coding team once a week to ensure the reliability of the content analysis for such a large project. In these meetings, small samples of articles were annotated by the coders and then discussed under the supervision of an experienced project leader. Intercoder reliability was then measured with an ex-post reliability test based on a random sample of n = 525 articles of the 2019 data . Three newly hired coders annotated the articles. This procedure allowed us to ensure the instrument's reliability independent of the coders at work, which we see as important for such a long-term research project with occasional changes in the coding team. The Krippendorff's alpha values for all variables were satisfactory and ranged from 0.77 to 0.90 . Regarding the surveys, the internal consistency reliability scores were 0.90 for the three-item relevance subscale, 0.93 for the four-item contextualization subscale, 0.93 for the four-item professionalism subscale, and 0.90 for the fouritem diversity subscale. We conducted an exploratory factor analysis with the firstround survey data to identify the underlying factor structure. The Kaiser-Meyer-Olkin measure and Bartlett's test of sphericity were very good, which indicate that the data was adequate to conduct a factor analysis. We were surprised that the results pointed to a one-factor solution , with all factor loadings ranging between 0.69 and 0.88 . Confirmatory factor analyses were conducted to identify one item per dimension that best reflects the criteria. The results show that news media quality is adequately reflected by the following four items: "…focuses on socially relevant topics in their reporting" , "… presents substantial background information on current topics" , "…focuses on arguments over emotions in their coverage" , and "…covers various perspectives in its reporting" . This measurement model has very good overall fit; therefore, an index score was calculated using these four items. The four items can be used as a brief reliable and valid short scale for E: Clearly distinguishes between news and opinions. 0.85 3.5 G: trennt klar zwischen Nachrichten und Meinungen. F: établit une distinction claire entre les actualités et les opinions. measuring news media quality. The reliability score of the total scores is also satisfactory with the data from each round . --- Results --- Situation Regarding News Media Quality in Switzerland Table 3 summarizes the results of both methods for each news media outlet. Overall, the content scores range from 3.9 to 8.3 , and the audience's assessments from 2.7 to 4.2 . In general, the best assessments were obtained for German-language public broadcasting programs produced by Swiss Radio and 10. E: Focuses on arguments over emotions in their coverage. 0.87 3.4 G: setzt in der Berichterstattung auf Argumente statt Emotionen. F: s'appuie sur des arguments plutôt que sur des émotions dans ses reportages 11. E: Presents their news sources transparently. 0.83 3.5 G: macht die Informationsquellen für die Nachrichten transparent. F: présente ses sources d'information de façon transparente. Diversity 12. E: Offers a complete overview of all the important events. 0.81 3.6 G: gibt einen vollständigen Überblick über alle wichtigen Ereignisse. F: fournit un aperçu complet de tous les événements importants. 13. E: Covers various perspectives in its reporting. 0.87 3.4 G: hat eine Berichterstattung, die aus mehreren Blickwinkeln erfolgt. F: réalise des reportages composés de plusieurs points de vue. 14. E: Reports about various topics. 0.69 3.9 G: berichtet über viele unterschiedliche Themen. F: aborde de nombreux sujets variés. 15. E: Conveys diverse perspectives and opinions. 0.84 3.5 G: gibt vielfältige Positionen und Meinungen wieder. F: présente des avis et des points de vue très variés. Note. . One-factor solution. Items were measured on a five-point Likert scale. The media outlet's name was made explicit in each item, for example: . Boldface indicates chosen items for the media quality index. Television . These include the following programs. Echo der Zeit,t h eflagship of Swiss radio, is a daily radio program that focuses on in-depth reporting; Rendez-vous is a daily radio program focused on current affairs; 10vor10 is a current affairs television program, and the Neue Zürcher Zeitung is both the highest-ranked newspaper and the highest-ranked private news media outlet . At the bottom of the table, one can see that the tabloid and free dailies obtained the worst rankings: 20 minutes is a free, French-language daily newspaper, while Blick and its online version blick.ch are known for sensationalism. --- Comparing Content and Audience Perspectives The results of this multimethod study demonstrate that the content analysis scores, based on deliberative theory, and audience assessments, regarding the quality of news media outlets, are very similar, as indicated in Figure 2. The higher a news media outlet is rated in terms of news media quality from our scholars' perspective , the better its quality is perceived from the audience perspective, and vice versa. This relationship is similar across two time points and different samples. We calculated simple linear regressions to analyze how the deliberative quality predict the audience's perceptions . In almost dimensions, significant regression equations were found , which means both methods assess the news media outlet's quality similarly. In both stages, the content scores and audiences' assessments correspond most highly regarding relevance and least-although still high-regarding contextualization. A detailed analysis of both stages shows that the older and more educated audiences are, the more highly the assessments correspond. --- Discussion and Conclusion In the context of revenue losses and cost-cutting measures, news media quality is a prominent topic today, with political, cultural, and economic implications. Valid quality measurements are therefore important to assess the situation of current media systems. But for a variety of reasons, particularly the double hermeneutics of social sciences, the definition, measurement, and operationalization of news media quality is difficult. The ways social scientists understand news media quality inevitably interacts with the meanings of these constructs shared by people in society, making news media quality a dynamic, contingent, and contested construct. This conceptual and methodological paper aims to reflect on the challenges of news media quality research, which every scientist who does media quality research should know. We set the boundaries of the term news media quality by identifying its four fundamental components . Within these boundaries, it outlines a deliberative understanding of news media quality based on Habermas' ideal of democracy, so it is open to scrutiny, reinterpretation, and redevelopment. Moreover, it operationalizes measures of news media quality, using the showcase of Switzerland, from both a content perspective and an audience perspective. Its matched research instruments allow the comparison of scientists' assessments rooted in democratic theory with audiences' perceptions. It therefore illuminates the relationship between audiences' perceptions and scientists' normative understandings. Finally, it provides long-and short-scale versions for measuring audience perceptions of news media quality from a deliberative perspective. However, it should be mentioned that the paper has its limitations. Regarding the conceptual part, it should be mentioned that neither method considers current debates around Habermas' deliberative theory. The current scientific debate on Habermas' work shows, however, that emotions do not have a quality-reducing effect per se, but can be conducive to discourse under certain conditions if they can be justified or if they promote empathy for opposition groups . Future research on news media quality should also evaluate the news media's "abilitytoengageinperspective taking and to feel empathic concern for others" . Both methods have their limitations as well. While the content analysis evaluates emotional reporting with low-quality scores, the survey items do not reflect the role of empathy. Regarding content analysis, the assignment of concrete scoring values is to some degree subjective. For example, the decision that "sport" is rated as scoring four points in terms of "relevance" cannot be fully derived from deliberative theory. Moreover, certain variables, such as objectivity, should be operationalized in a more differentiated manner. The survey, in turn, has a small number of respondents regarding some media outlets. The filter question plays a crucial role here, as respondents only assessed news media outlets they knew well or very well. However, we would argue that this multimethod study is more than the sum of its parts. It combines the strengths of two methods to reliably evaluate news media quality. Urban and Schweiger raised reasonable doubts about the ability of audiences to evaluate news media quality, because "normative news quality criteria are abstract, complex, and thereby hard to understand for media users" . However, this study's findings indicate that scholars and audiences share a common understanding of news media quality with respect to Switzerland. This partly confirms the results of van der Wurff and Schoenbach's large-scale survey from the Netherlands, according to which "the Dutch audience shares the journalists' professional expectations" . The high correlation between both methods of our study indicates a strong positive correlation between scientists' assessments rooted in deliberative theory and audiences' perceptions . Considering the financial problems of the news media in times of digitization, in particular, due to the drop in advertising revenues and many people's unwillingness or inability to pay for good journalism, we see a task of future research to conduct cross-national comparative analyses in a similar manner, exploring whether or not the normative understandings of deliberative politics are anchored in society and shared by audiences. According to Hallin and Mancini , Switzerland represents the "democratic corporatist model," characterized, among other things, by strong newspapers, a strong public service media, and a strong journalistic professionalization . Future research could investigate if there is similar agreement between scientists and the audience on news media systems in other news systems. Although our data relates to Swiss news media, we argue that our study is not limited to Switzerland, because its theory and methodology apply to other countries and media systems. --- Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article. --- ORCID iD Philipp Bachmann https://orcid.org/0000-0001-9399-569X --- Supplemental material Supplemental material for this article is available online. --- Author Biographies

High-quality news is important, not only for its own sake but also for its political implications. However, defining, operationalizing, and measuring news media quality is difficult, because evaluative criteria depend upon beliefs about the ideal society, which are inherently contested. This conceptual and methodological paper outlines important considerations for defining news media quality before developing and applying a multimethod approach to measure it. We refer to Giddens' notion of double hermeneutics, which reveals that the ways social scientists understand constructs inevitably interact with the meanings of these constructs shared by people in society. Reflecting the two-way relationship between society and social sciences enables us to recognize news media quality as a dynamic, contingent, and contested construct and, at the same time, to reason our understanding of news media quality, which we derive from Habermas' ideal of deliberative democracy. Moreover, we investigate the Swiss media system to showcase our measurement approach in a repeated data collection from 2017 to 2020. We assess the content quality of fifty news media outlets using four criteria derived from the deliberative ideal (N = 20,931 and 18,559 news articles and broadcasting items, respectively) and compare the results with those from two representative online surveys (N = 2,169 and 2,159 respondents). The high correlations between both methods show that a deliberative understanding of news media quality is anchored in Swiss society and shared by audiences. This paper shall serve as a showcase to reflect and measure news media quality across other countries and media systems.

education, with 1-2 living children, or whose partners had only primary level schooling displayed higher adjusted prevalence rates for both IPEV and IPPV, but not for IPSV. However, relative to their counterparts whose partners were aged 25 years or below, living with a partner aged 40 years and above was associated with statistically significant reduced prevalence rates for IPPV and IPSV, but not for IPEV. Only for IPPV did women with partners educated at secondary and above levels display statistically significant higher adjusted prevalence rates relative to their counterparts with uneducated partners. Also, solely for IPPV did women who began cohabiting between ages 18 and 24 years or whose partners were employed show decreased adjusted prevalence rates relative to their counterparts who started cohabiting before 18 years or whose partners were unemployed. In addition, only for IPSV did women aged 40 years and above or living in middle wealth households show statistically significant reduced adjusted prevalence rates relative to their counterparts aged less than 25 years or living in lower wealth households. --- Introduction Intimate partner violence is any behavior, within an intimate relationship, that causes physical, psychological, or sexual harm [1]. It is a leading public health problem and one of the commonest forms of violations experienced by women globally [2]. The implications of IPV are far-reaching, extending beyond women's physical, emotional, sexual and reproductive health, to encompass their overall well-being, the welfare of their households and communities, and even the economic and social fabric of societies [3]. Among women who suffer intimate partner violence, injuries, visits to health personnel, disabilities and deaths are common [3][4][5]. Violence corrodes women's confidence and mental health, hampering their productivity and contribution to development. Abused women often experience emotional distress and tend to consider, attempt, or carry out suicide frequently. They suffer post-traumatic stress syndrome, depression, anxiety, and low self-esteem and other adverse behavioral outcomes such as alcohol and drug abuse, sexual risk-taking, and a higher risk of subsequent victimization [6]. IPV distresses families and communities. It drains household resources, strains family ties, and depresses family members [7,8]. To avoid further violence, abuse and stigma, women survivors of IPV may amend their behaviors to what is acceptable to their aggressors and victimizers, often becoming their own jailers [9]. Although most African countries have assented to many international declarations and developed several national laws that aim to eliminate violence against women, IPV remains widespread in the continent [10,11]. Nearly 40% of ever-partnered women in Africa have experienced physical and/or sexual intimate partner violence at some point in their lives [11]. Urban settings are increasingly critical for efforts to understand and address IPV in Africa. Most of the region is undergoing rapid urban growth under challenging socio-economic conditions. A significant proportion of the future population growth in SSA will occur in urban areas, and by 2050, 50% of the region's population is expected to be city dwellers [12]. The majority of residents in SSA's largest cities-and a swelling proportion of Africans overall-now live in compromised, congested informal settlements, also called slums [13]. The prevalence of IPV against women in SSA is often higher in impoverished urban settlements than in the general urban population [14][15][16]. Men and boys who live in poor urban communities have also been described as central to the growing epidemic of deadly IPV against women in SSA [17]. With growing realization that the future of global women's health is urban [18], understanding the dynamics of and tackling IPV in African cities have become both urgent and critical. But while increasing urbanization in the global south may exacerbate women's exposure to violence and poor health [19][20][21], the intersections of IPV and urbanization have been ignored or remain poorly studied. Research has associated a variety of socio-economic factors operating at multiple levels with IPV among urban women [15,[21][22][23][24][25][26][27]. However, these associations are not clear for different IPV subtypes, for different categories of women, and for different countries in the region. Existing IPV studies among urban women in Africa are mainly comparisons of urban and rural areas of Africa [28,29]; focus on the relationship between IPV and health and other outcomes among urban women [7,30], and address poor urban women's specific risk factors for IPV [31,32]. Few studies explicitly focus the subtypes of IPV among urban women [9]. Even when they do, the bulk of these studies ignore the broader dynamics of IPV within and between countries in SSA and/or use data that is not representative of urban women in the countries and sub-region [9,32,33]. As Africa's urban population continues to swell, efforts to tackle IPV require robust characterizations of the women at risk for different forms of IPV; grounded analyses of the intersections of factors that expose women to risk; and focused explorations of country-and regionallevel dynamics of women's experiences of IPV forms. The current study is the first major multicounty study of IPV among urban SSA women. It uses comparable, nationally representative data from 27 SSA countries to ask: 1) What are the magnitude and patterns of IPV and its subtypes within and between selected countries in SSA? 2) What factors are associated with the prevalence and experience of IPV subtypes among urban SSA women; and 3) how does the prevalence of IPV subtypes vary within and between countries in SSA? Utilizing a multilevel approach, the study: provides a profile of urban women who experience IPV and its subtypes within and across selected countries in SSA; and , tests the central hypothesis that the prevalence of IPV subtypes among urban women differs within and across SSA countries based on survivor-, partner-, and household-level characteristics. The study responds to a growing need for comparative insights on the dynamics of IPV in contexts and spaces that are critical for the future of women's health, and for evidence to strengthen national, regional and global responses to IPV. --- Method --- Participants and procedures The study uses pooled data from 42,143 urban women aged Eligibility for the Domestic Violence Module includes being female, 15-49 years of age, able to complete the survey privately, currently or previously married, and/or living with a male partner. All DHS tools are translated and adapted for each country and then piloted in clusters not selected for inclusion in the survey to assess questionnaire quality . Approximately 2,940 of women that were eligible and agreed to participate in the study countries did not complete the interview due to privacy concerns. The 27 countries and timing of the Demographic and Health Surveys used in the current study are shown in Table 1. Patterns of missingness were examined and found to be minimal . The response rate among women completing the Domestic Violence Module stood at 98.2%. --- Measures and variables The outcome variables for this study are experiences of any form of IPV, namely physical violence, sexual violence and emotional violence. The DHS asks several different questions to establish if a woman has suffered a form of IPV-physical, sexual and / or emotional violence. Women who are currently or were formerly married or in union, responded to a set of thirteen questions . Responses to the questions were grouped into either physical, sexual or emotional. Each outcome variable was coded '0' when the respondent did not experience it, and '1', when it was reported as having occurred. Explanatory variables in the study were selected individual-, household-and partner-level socio-economic and demographic factors, including responding women's age, level of education, employment status, age at first cohabitation, number of children alive and beliefs regarding wife-beating. Other adjusted variables were the age, level of education, and occupation of the responding women's spouses or partners, the household wealth and union types of the --- Data analysis Statistical analyses were run at univariate, bivariate and multivariate levels. Estimates of the prevalence of outcomes and explanatory variables are presented at the univariate level and --- Outcome variables Physical violence spouse ever pushed, shook or threw something at respondent; spouse ever slapped respondent; spouse ever twisted respondent's arm or pulled her hair; spouse ever punched respondent with fist or something harmful; spouse ever kicked; dragged or beat up respondent; spouse ever tried to strangle or burn respondent; spouse ever threatened respondent with knife/gun or another weapon; spouse ever attacked respondent with knife/gun or another weapon yes = experience of at least one of the listed acts of violence No = experience of none of the listed acts of violence Sexual Violence spouse ever physically forced respondent to have sex when not wanted; spouse ever forced other sexual acts when not wanted by respondent; spouse ever used threats to force sexual acts when not wanted by respondent? yes = experience of at least one of the listed acts of violence no = experience of none of the listed acts of violence Emotional Violence spouse ever said or did something to humiliate respondent in front of others; spouse ever threatened to hurt or harm respondent including close relatives; spouse ever insulted or made respondent feel bad yes = experience of at least one of the listed acts of violence no = experience of none of the listed acts of violence https://doi.org/10.1371/journal.pone.0230508.t002 stratified at the individual, household, partner, and country levels. Associations between and levels of significance of explanatory, adjusted and outcome variables were examined at the bivariate level using Pearson Chi-square tests. A multilevel generalized linear model with Poisson distribution measured associations between individual-, household-and partner-level variables and IPV within and between countries. Following the lead of previous studies on IPV [45][46][47], we relied on the modified Poisson regression approach to estimate the incidence ratio and 95% confidence interval of experiencing IPV. We adjusted for selected variables at the multivariate analysis level using three models. Model I was restricted to associations between selected individual characteristics and outcome variables at both within-and between-country levels. Model II included partner-characteristics and model I. Model III included Model I, Model II as well as household-level variables to assess effect measure modification. The model was fitted using the Hosmer Lemeshow Test. All analyses incorporated sampling weights to account for complex survey design and the unequal probability of selection for each participant in the survey. Standard errors for cluster sampling of the primary sampling units were also adjusted for using svyset commands in Stata. Before results were interpreted, multicollinearity between explanatory variables was assessed through the variance inflation factors at a reference value of 5. All study estimates were weighted appropriately using the weights assigned to the domestic module in the DHS dataset. Significance levels were estimated at p<0.05, p<0.01 and p<0.001. Analysis was conducted using STATA 15.1 . --- Results Fig ). IPPV prevalence rate was lowest among women in the higher wealth category in South Africa , and in women aged 40 and above in Comoros. It was highest among women in the lower wealth status in Gabon and Burundi , ranged from 6.9% to 47.9% in women aged 25 to 39 in Comoros and Sierra Leone respectively, and from 3.6% to 44.2% in women aged above 39 years in Comoros and DRC respectively. IPSV was most commonly reported among women in the lowest wealth status in Cote d' Ivoire and lowest among women aged 40 and above in Comoros; women in the highest wealth category in Gambia , and women in formal employment in Ethiopia . Prevalence of IPEV was lowest among women in the highest wealth category in Comoros and highest among women in the lowest wealth status in Togo and Cote d'Ivoire , and among women in informal employment in Cameroun . Bivariate tests of association indicated that while all the explanatory variables of interest were significantly associated with IPPV in Uganda, none was significantly associated with it in Chad and Senegal. In Malawi, Mali, and Sierra Leone, only women's educational level, women's occupation, and the number of living children were respectively associated with IPPV. None of the explanatory variables at the bivariate level showed significant association with IPSV in Burkina Faso, Chad, Mali, and Senegal. In Comoros and Sierra Leone respectively, only women's educational level and women's approval of wife-beating were significantly associated with IPSV. No association was evident at the bivariate level between the explanatory variables and IPEV in Chad, Mozambique, and Namibia. In Angola, Sierra Leone, and South Africa, only spousal educational level, spousal occupation, and women's attitude towards wifebeating respectively, were significantly associated with IPEV prevalence. The only variable that was not significantly associated with IPEV prevalence in Burundi was the woman's age . --- Intimate partner physical violence Regression results for IPPV and selected variables, including IRRs and their associated CIs are provided in Table 3. Women's educational level was positively associated with an increased prevalence rate for IPPV. Compared to women without formal education, women with primary education had a 27% higher adjusted prevalence rate for IPPV. Women with secondary and higher education also had 1.25 times greater adjusted prevalence rate than that of uneducated women . Informal employment was associated with significantly heightened rates for IPPV. In Model III, women in informal employment had a prevalence rate for IPPV 1.17 times that of unemployed women . Higher ages at first cohabitation were associated with decreased prevalence for IPPV. In the adjusted model, women who began cohabitating between ages 18 and 24 experienced a 5% decreased IPPV prevalence rate relative to women who began cohabiting earlier than their 18 th birthday. Also, women who began to cohabit between ages 25 and 34 had a 27% lower adjusted IPPV prevalence rate than those who started cohabiting earlier than 18 years. Having higher numbers of living children was associated with higher IPPV prevalence rates. In the adjusted model, women with 1-2, 3-4, and 5 + living children had 28%, 44%, and 42% respectively higher prevalence rate of IPPV than women without a living child. Women who approve of wife-beating also had 1.30 times higher adjusted IPPV prevalence rate than those who do not and women whose partners were aged 40 years and above had a 16% lower adjusted prevalence rate for IPPV compared to women whose partners were aged less than 25 years. Interestingly, having a partner with only primary education and having a partner with secondary and higher level of education were both independently associated with an increased IPPV rate in Model III. In the adjusted model, the prevalence rate for IPPV among the former women was 1.22 times , and among the latter group of women, 1.09 times greater than women whose partners had no formal education. In the same model, partners' employment status was also significantly associated with rates for IPPV among women: respondents whose partners were in informal employment and those whose partners were in formal employment respectively had 10% and 19% decreased IPPV prevalence rates compared to women with unemployed partners. While higher household wealth was associated with a decreased adjusted prevalence rate for IPPV, women in polygynous households reported IPPV 14% times more than women in monogamous unions. In Model I, women in Cameroun, Sierra Leone and Gabon had higher IPPV prevalence rates compared to women in DRC. However, this was only significant in Gabon. In Model II, the reduced IPPV prevalence rates among urban women in the region relative to the DRC counterparts remained generally stable, becoming statistically significant in Sierra Leone and Gabon, but slightly attenuating in significance in Chad. In Model III, the IPPV prevalence rate patterns among urban women in the region relative to their counterparts in DRC were also largely retained, though women in Gabon lost some of their comparative advantages relative to their DRC counterparts. --- Intimate partner sexual violence Table 4 shows the prevalence rates for IPSV and associated IRRs and CIs. Women aged 40 years and above had a 22% lower adjusted prevalence rate for IPSV compared to their counterparts aged less than 25 years. On the other hand, women with only primary-level education and women in informal employment showed higher adjusted IPSV prevalence rates relative to their uneducated and unemployed counterparts respectively. IPSV prevalence rate was also higher among women with 3 and more living children than in their counterparts with no living child. Compared to those without a living child, women with 3-4 and 5 + living children had 35% and 30% higher prevalence rate respectively for IPSV. Women who approve of wifebeating also had a 63% higher adjusted prevalence rate for IPSV than those who do not. And relative to their counterparts who started cohabiting earlier than their 18th birthday, women who began cohabiting between their 25 th and 34 th birthdays had a 32% diminished adjusted IPSV prevalence rate. The prevalence of IPSV was lower in women whose partners were aged 40 years and above than in women whose partners were aged less than 25 years. The former group women had a 24% lower adjusted prevalence of IPSV compared to the latter. Women in middle and in higher wealth households also had decreased IPSV prevalence rates respectively) compared to their counterparts in lower wealth households. However, being in a polygynous union increased IPSV prevalence rate in women by 21% compared to living in monogamous households. In Model I, urban women in the region generally showed significantly reduced prevalence rates of IPSV compared to their counterparts in DRC, except in Gabon, Malawi, Rwanda, and Uganda. In Model II, while IPSV prevalence rates remained significantly stable across the countries, Burundian women displayed a sturdier reduced IPSV prevalence rate compared to their DRC counterparts. In Model III, with the exceptions of Burkina Faso, Burundi and Chad, the region's urban women generally retained their statistically significant reduced IPSV prevalence rates compared to their counterparts in DRC. --- Intimate partner emotional violence Table 5 shows regression results for IPEV prevalence rates and selected variables. Controlling for all variables, women with only primary-level education or with secondary and above levels of education respectively had 25% or 28% higher IPEV prevalence rates than their uneducated counterparts. The higher prevalence rate for IPEV among women in informal employment, compared to their unemployed counterparts, found in Models I and II remained significant in Model III . Across the models, women who began cohabiting between their 25th and 34 th birthdays retained consistently decreased prevalence rates for IPEV relative to those who began cohabiting earlier than their 18 th birthday. In Models I, II and III, the former group of women had 19%, 18% and 18% decreased prevalence rate for IPEV compared to the latter group. Numbers of living child were associated with increased IPEV prevalence rates: women with 1-2, 3-4, and 5 + living children had 27%, 46%, and 43% respectively higher adjusted prevalence rate of IPPV than women without a living child. Also, the higher prevalence rates for IPEV among women who approve of wife-beating, compared to their counterparts who do not, found in Models I and II remained statistically significant, diminishing only slightly in the full model . On the other hand, the higher IPEV prevalence rate among women whose partners had only primary-level education relative to women with uneducated partners rose from 19% in Model II to 21% in Model III. Further, while women in higher wealth households showed decreased adjusted IPEV prevalence rates relative to their counterparts from lower wealth households, being in polygynous unions amplified women's IPEV prevalence rate by 14% compared to their monogamous counterparts. In Model I, only in Benin, Cameroun, Gabon, Mozambique, and Sierra Leone did urban women display statistically significant higher IPEV prevalence rates compared to their DRC counterparts. In the same model, urban women in 12 of the countries had significantly decreased IPEV prevalence rates compared to their counterparts in DRC. These patterns were largely retained in Models II and III. However, it was only in Model III that Namibian women joined the bulk of the region's women to experience a statistically significant reduced IPEV prevalence rate relative to their DRC counterparts. --- Discussion This paper is arguably the first truly regional exploration of prevalence rates for IPV subtypes among urban women across SSA. By focusing on IPV subtypes and their particular correlates in urban women across 27 countries in SSA, the study constitutes a major shift from research that treats IPV as an invariable phenomenon or focuses only on a few of its forms in few African contexts [5,32,33,48]. Some notable patterns and findings emerge from the study. Descriptive findings showed critical patterns in the extent, magnitude and correlates of IPV forms in different countries and among diverse groups of women in SSA. In general, urban IPV rates among urban women in the countries we studied closely mirror prevalence rates of IPV globally, nationally and regionally. Globally, over a third of women have experienced physical and/or sexual violence by a partner or non-partner. A WHO study showed that the global lifetime prevalence of IPV among ever-partnered women for Africa was nearly 40% [11]. In Nigeria, estimates put the prevalence of IPV at 31% to 61% for psychological/emotional violence, 20% to 31% for sexual violence, and 7% to 31% for physical violence [49]. While IPPV has been the focus of many studies, the current research shows that IPEV and IPSV are also common in urban areas in SSA. The low report for IPSV should, however, be interpreted with caution. IPSV remains a taboo topic in many African contexts. As a result, few survivors feel comfortable to report it in surveys [50]. With regards to IPV in urban SSA, Comorian women were safest while women in DRC were the least unsafe. The proportion of urban women in SSA who report IPV is significantly high in conflict and post-conflict states such as DRC, Uganda, and Sierra Leone. Conflict and post-conflict situations increase women's risk for violence within and outside unions [47,[51][52][53][54][55]. Social protection mechanisms deteriorate at multiple levels during conflicts, intensifying the conditions and circumstances that expose women to risks for violence [40,56]. Our findings indicate the unique dynamics of IPV in urban SSA. To illustrate, only five correlates-having only primary-level education, having 3 or more living children, being informally employed, being in polygynous unions, or supporting wife-beating-were commonly associated with higher adjusted prevalence rates for all three forms of IPV. Conversely, two variables-starting to cohabit between ages 25 and 35 years or living in higher wealth households showed consistently lower adjusted prevalence rates for all three forms of IPV. Relative to their counterparts without formal education, without a living child, or whose partners did not have formal education, women with secondary and higher education, with 1-2 living children, or whose partners had only primary level schooling exhibited higher adjusted prevalence rates for both IPEV and IPPV, but not for IPSV. Also, in comparison with their counterparts whose partners were aged 25 years or below, living with a partner aged 40 years and above was statistically associated with reduced prevalence rates for IPPV and IPSV, but not for IPEV. Only for IPPV did women with partners educated at secondary and above levels display statistically significant higher adjusted prevalence rates relative to their counterparts with uneducated partners. Only for IPPV too did women who began cohabiting between ages 18 and 24 years or whose partners were employed show decreased adjusted prevalence rates relative to their counterparts who started cohabiting before 18 years or whose partners were unemployed. However, it was only for IPSV that women aged 40 years and above or living in middle wealth households showed statistically significant reduced adjusted prevalence rates relative to their counterparts aged less than 25 years or living in lower wealth households. Many of these findings challenge existing studies, raising the need for multifaceted interventions that respond to the unique complexities of IPV and its subtypes in the region's urban contexts. For instance, research suggests that men with higher educational attainment have more equitable attitudes and practices towards women and may be less violent to their marital partners [57]. Our study suggested otherwise, at least for IPPV. These inconsistencies also imply that there may be other variables operating at the partner-and household-level characteristics that need further exploration. There is, for example, ample evidence that substance and alcohol abuse by male partners can exacerbate violence in the household [58][59][60][61][62]. Among the critical findings in this study is the link between IPV, gender dynamics, and marital power inequities. IPV is often used to maintain and assert power by men [39,63,64]. Situations that diminish men's sense of control over their female partners can exacerbate their use of violence to affirm control and power [65,66]. Threats to men's feelings of power in intimate relationships can emerge from diverse sources, including the stresses and disruptions associated with conflicts and post-conflict situations [40,55]. There is evidence that some men may find economically independent and educated female partners threatening. IPV can be part of such threatened men's strategies to enforce control over female partners [67]. Further, while education can facilitate woman's recognition and reporting of IPV generally, it can also increase women's risk for IPV. Educated women may threaten men's sense of themselves as household heads, decision-makers and breadwinners, especially if such men subscribe to traditional masculine norms regarding the role and authority of men in the household [68]. Also, while previous research shows that economically dependent women are particularly at risk of IPV [69,70], there is also evidence that such women may resort to relationship practices that shield them from violence. Such strategies may include non-confrontation, subservience, and other conflict avoidance strategies [71]. The implications of marital power inequities for IPV in urban SSA are also evident in the positive associations between polygyny and all IPV forms. Polygyny is related to and can boost gender inequities that could promote IPV. Violence toward women can be potentiated by polygyny which often goes together and, in combination with women's low economic power, low educational attainment, and weak decision-making power. Polygyny enhances male control over women in ways that allow and encourage violence and suppression of rights and liberties of women and girls [72,73]. Additionally, urban women who approved of wife-beating had a significantly elevated prevalence of all forms of IPV relative to their counterparts who did not. Women who approve of wife-beating in unions tend to be poorer, adolescents, or marry early. They are also often powerless and marginalized in their unions, showing inadequate capacity to safely challenge their partners and prevent their abuse or violation. One study in Kenya showed that 36% of girls married before 18 believed that a man is sometimes justified in beating his wife, compared to 20 percent of those who married later [74]. Early ages at cohabitation were associated with increased prevalence rates for IPV. Women who started to cohabit between ages 25 and 35 years had much lower adjusted prevalence rates for all three forms of IPV relative to their counterparts who began to cohabit before age 18. Doku and Asante [75] write that early marriage exacerbates power inequities in unions, putting the woman at extended risks for IPV. Girls who marry before 18 are more likely to experience domestic violence than their peers who marry later. In Peru, where more than half of women report physical or sexual violence, early age at marriage aggravated women's risk for IPV [76]. The elevated prevalence rates for all IPV forms among women with higher numbers of living children is another critical finding. Large families can be a source of enormous pressure and frustrations that can strain unions and precipitate violence. Research shows that the cost of children is rising in SSA at a time of widespread inflation, unemployment, and growing cost of living [77]. Years of structural adjustment, poor development planning, and decline of public protection and social services have shrunk livelihood opportunities for many urban SSA families, systematically depleting their ability to maintain a decent living and resulting in hardship, poverty and deterioration in the quality of life [13]. These trends have potential to create tensions that can promote IPV [77,78]. Scholars have noted the systematic erosion of the advantages which urban areas have historically enjoyed over rural areas in Africa in terms of livelihood opportunities, social protection, health access to services, and disconnection from traditional gender norms [79][80][81]. --- Conclusion In just a decade, the majority of SSA women will be urban dwellers. IPV remains a common public health problem and one of the most prevalent forms of violations of women's human rights globally [4,7]. Efforts to address IPV in Africa must include a strong focus on urban areas. The current multi-country study sought to understand the broader dynamics of IPV and its forms in urban SSA using representative data on urban women in the sub-region. The study showed that the prevalence of IPV is highest in conflict and post-conflict states such as DRC and Sierra Leone. It also highlights the complexities and varying influences on IPV subtypes in urban SSA. The factors associated with urban African women's exposure to different IPV subtypes can be both similar and unique at the same time. Future research should explore the contextual and community-level factors that may be associated with IPV against urban women in Africa, as documented in previous research [82]. This study used a cross-sectional dataset and was unable to track trends and changes over time with respect to IPV forms and their correlates in SSA. This limitation notwithstanding, the study reveals some important dynamics, correlates and complexities surrounding IPV in contemporary urban SSA. --- All relevant data are within the paper and its Supporting Information files. --- Supporting information --- S1 Table. Proportions of currently-in-union urban SSA women who have experienced more than a form of IPV. --- S2

The dynamics of intimate partner violence (IPV)-one of the world's leading public health problems-in urban Africa remain poorly understood. Yet, urban areas are key to the future of women's health in Africa.We explored survivor-, partner-, and household-level correlates of prevalence rates for types of IPV in urban SSA women.The study uses DHS data from 42,143 urban women aged 15-49 in 27 SSA countries. Associations at the bivariate level were examined using the Pearson Chi-square test. The modified Poisson regression test estimated the relative prevalence of IPV subtypes in the study population at the multivariate level.Approximately 36% of women in urban SSA experienced at least one form of IPV; 12.8% experienced two types; and 4.6% experienced all three types. SSA urban women who had only primary-level education, had 3 or more living children, were informally employed, were in polygynous unions, or who approved of wife-beating similarly displayed higher adjusted prevalence rates for all three forms of IPV compared respectively to their counterparts without formal education, without a living child, were unemployed, in monogamous unions, or who do not approve of wife-beating. On the other hand, the region's urban women who began cohabiting between ages 25 and 35 years or who lived in higher wealth households showed consistently lower adjusted prevalence rates for all three forms of IPV relative to their counterparts who began cohabiting before 18 years or who lived in lower wealth households. Compared to their counterparts without formal education, without a living child, or whose partners did not have formal education, women with secondary and higher

INTRODUCTION Syphilis in pregnant women is associated with risks for both the woman and the fetus due to vertical transmission , such as abortion, premature birth, neonatal death, low birth weight, neonatal neurological impairment, including cognitive delay, vision loss, convulsive disorders, and bone malformations . Congenital syphilis is a condition that can be prevented by controlling syphilis in women and their sexual partners during family or prenatal planning . In 2016, the worldwide prevalence of syphilis in pregnant women was estimated at 0.69%, resulting in an overall CS rate of 473 cases per 100,000 live births . In Brazil, a considerable increase has been observed in the CS rate -in 2008, 2 cases were reported per 1,000 live births and in 2020, 7.7 cases per 1,000 live births , very far from the goal of 0.5 cases per 1,000 live births by 2015, as defined by the World Health Organization , also confirmed for 2030 . The prevention of vertical transmission of syphilis supports the Sustainable Development Goals issued by the United Nations for the period from 2016 to 2030, to which Brazil is a signatory. One of the targets is to end preventable deaths of newborns and children under five years old . Worldwide, the neonatal component corresponds to 44% of infant mortality the main causes are prematurity and congenital malformation , which can be consequences of CS . Congenital syphilis is considered a marker of prenatal care quality, since vertical transmission can be 100% prevented with timely diagnosis and adequate treatment of the pregnant woman . Prevention and treatment involve complex issues related to gender, sexuality, marital infidelity, prejudice, and discrimination within the family and in health services . The experience of being diagnosed with syphilis and transmitting the disease to the child generates feelings of sadness, fear, shock, guilt that become more intense as the NB remains hospitalized to treat the disease . Stigma by health professionals and family members is also observed in the diagnosis of syphilis , leading to omission of the disease within the family , which restricts support at an important moment for building parenthood . Nurses can prevent vertical transmission through health promotion and self-care for women and their partners, as well as quality prenatal care . In the hospital environment, when CS is diagnosed, many mothers are surprised and shocked, as they did not expect the child to be infected and need support and guidance from nurses regarding the diagnosis, treatment, and health care, not only for them, but also with the NB 18) . Although many studies have been developed with a focus on prenatal care and treatments for both syphilis during pregnancy and CS, the evidence is based on epidemiological data . There is a gap in the literature about the symbolic representations and meanings involved in actions and practices of women before the child's birth to avoid vertical transmission and, after birth, when following up the health of the child with CS. Understanding the intersubjective aspects involved in this experience can support and enhance nursing care. In this sense, the guiding question of this study was: What are the meanings attributed by women to the diagnosis and treatment of syphilis and CS, and to outpatient follow-up of their children? --- OBJECTIVES To understand the meanings attributed by women to the diagnosis and treatment of syphilis and CS, and to outpatient follow-up of their children. --- METHODS --- Ethical aspects This study was approved by the Research Ethics Committee of the Ribeirão Preto College of Nursing at the University of São Paulo and complied with the ethical requirements in Resolution 466/2012 of the National Health Council. Participants were identified by the letter E, followed by an Arabic numeral. --- Theoretical and methodological framework The theoretical framework used in this study was symbolic interactionism , since it values the meaning of the phenomenon for individuals in a given context, aiming to understand the deeper dimension of their actions and interactions in the search for these meanings. From the SI perspective, things assume meanings in the individual's interaction with others and while the individual consciously watches, reflects and thinks about the object and then interprets it . Symbolic interactionism helps understand the meanings of diagnosis, treatment, and outpatient follow-up of the children's health that emerge from interactions, and defines the actions of mothers in the child care process. The symbol , the self , the mind , human actions , and interactions support these women while they build their trajectories. --- Study design This is a qualitative study with an approach based on SI and inductive thematic analysis . In order to qualify the study production, the guidelines of the Consolidated Criteria for Reporting Qualitative Research were adopted. --- Study setting This study was conducted in a city in the northeast region of the state of São Paulo, which has a broad health network offering primary care services, high complexity and specialized care. In 2014, a reference center for specialties was inaugurated, which includes a municipal outpatient service for congenital infections, where our study was conducted. The reference center treats patients from the Brazilian Unified Health System living in the municipality, with sexually transmitted infections , tuberculosis, and viral hepatitis. It has a specialized care service and a testing and reception center. The reference center is linked of Syphilis in pregnancy and congenital syphilis: women's experiences from the perspective of symbolic interactionism Vicente JB, Sanguino GZ, Riccioppo MRPL, Santos MR, Furtado MCC. to municipal programs for primary care, women's health care, and child and adolescent health care. For newborns with CS, referral is made by the Floresce uma Vida program team, under the child and adolescent health care program. The team schedules the first appointment of the NB in primary care after discharge from the maternity ward. If risks are identified for the neonate, visits are also scheduled in specialized services such as the early stimulation service and the municipal outpatient service for congenital infections . At the outpatient service, children are followed up with monthly visits up to 6 months of age, and bimonthly after that period. --- Data source Thirty mothers of children with CS were contacted and all of them agreed to participate in the study. Inclusion criteria were: mothers aged 18 years or older and children being followed up by the outpatient service for at least three months . This follow-up period was selected as it would constitute an important limiting factor to understand this experience. Mothers were approached in the outpatient waiting room, on the days of child care, and were invited to participate in the study. --- Data collection and organization Data collection took place between March and October 2018 through individual semi-structured interviews conducted by the main researcher with experience in qualitative studies, in a private room provided by the health service. The interviews were audio-recorded and lasted around 40 minutes. The interview was based on the guiding request: "Tell me about your child's care, from birth to this moment". Supporting questions sought to encourage mothers to tell their experience in detail, for instance: "How and when did you find out you had syphilis?"; "Did you know about the effects of this disease on your child?"; "When and how did you find out your child had CS?"; "How was the treatment ?"; "How is the outpatient follow-up going?"; "What are your perceptions and feelings regarding CS?". A field diary was filled with relevant notes to the interview process, which cannot be audio recorded . This information was included in interview transcripts. The field diary was filled at the end of each interview. All participants were able to listen to their interviews, making further comments or corrections; however, no participant requested any insertion or adaptation. Data collection ended when the researcher reached the study objective. An ideal qualitative sample reflects the multiple dimensions of the phenomenon and seeks quality of actions and interactions, highlighting the researcher's certainty of finding the internal logic of the study objective . --- Data analysis Interviews were transcribed by the main researcher and validated by another researcher. Through inductive thematic analysis , the latent content analysis was performed, guided by data and interpreted according to SI. Inductive thematic analysis goes beyond the semantic content of data and identifies ideas, assumptions, and concepts, while the development of themes involves interpretation, not just data description . This analysis consists of six stages. In stage 1, the repeated reading of data was performed, seeking meanings and patterns; in stage 2, the initial codes were organized; in stage 3, themes were identified by highlighting repeated words, expressions, and phrases and the contents addressed with more emphasis, then an initial thematic map was built. Themes were refined in stage 4, when the thematic map was developed. In stage 5, the themes were defined and named . Also in stage 5, data analysis was written, with the organization of excerpts in agreement with the supporting text and interpretation based on SI; and in stage 6, representative data excerpts were defined for each theme, and the analysis, study question, literature, and theoretical framework were all correlated. Two themes were identified after the analysis: 'Diagnosis of syphilis and transmission of the disease to children: women's experience from shock to frustration' and 'Resignification of the experience with the disease: treatment and outpatient follow-up of the children' . --- RESULTS The study participants were between 18 and 38 years old ; 21 of them were married, 7 were divorced and 2 were single; 10 were multiparous . Regarding the children, 16 were male and 14 were female, aged 3 to 12 months . --- Theme 1: Diagnosis of syphilis and transmission of the disease to children: women's experience from shock to frustration When the pregnant women were diagnosed with syphilis during pregnancy, they related the disease to the human immunodeficiency virus , an incurable STI, they felt shocked, ashamed, guilty, and worried about transmitting the disease to their children. The symbolic meaning of syphilis as a disease related to promiscuity was aggravated by the fear of facing stigmatized social attitudes, especially from family members and health professionals, so they opted for confidentiality of disease information to protect themselves from prejudice and judgment. This symbolic meaning was rebuilt as they acquired more knowledge about the disease, maternal treatment, healing, and prevention of vertical transmission. These women, as social actors, assumed the role of mothers, and made an effort to protect their children. Such effort represents their attitudes during treatment, when they had feelings of concern, guilt, and responsibility for the well-being of their babies. To the diagnosis of CS, the women attributed the meaning of failure in their parental role, since they made an effort during pregnancy, in vain, to avoid vertical transmission. Guilt, concern, and fear were accentuated by the feeling of frustration due to the failure to prevent CS. --- I was very scared and worried and prayed that nothing serious would happen to him [...]. I felt very bad, I was really worried, because if I have that, that's ok, but it is not her [daughter] fault, right? I felt guilty, because I had follow-up care so nothing would happen to her, so she would be born well, and in the end, it was useless. So, I felt guilty for her having this disease, you know? [...] like it or not, it was my fault. Theme 2: Resignification of the experience with the disease: treatment and outpatient follow-up of the children The children of the study participants were hospitalized for an average of 10 days after birth to be treated for CS with intravenous crystalline penicillin. Seeing their children undergoing a painful clinical procedure, although for healing, increased their guilt and frustration due to vertical transmission. I cried, I cried a lot, because I wanted it to be positive for me, not for him, and every time he was going to get an injection [intravenous medication for treatment], I cried a lot [...] I woke up at night and dreamed, and prayed, put it on me, but take it off from him. I felt defeated, very defeated, such a tiny little baby! The day at the maternity hospital, when I saw her [daughter] there with the needle receiving [medication] I cried a lot, because I felt very guilty. [...] I lost 12 days, right, I could be at home enjoying my daughter, but we were in the hospital, every 6 hours she received the medication in the vein, then the vein burst and they had to puncture her, it was terrible. Resignification of the experience occurred in the symbolic process of discovering the possible impact of CS on the healthy growth and development of the children, which would be avoided with treatment. Although hospitalization was difficult for the women, it meant healing and the well-being of their babies. --- He was infected and took the injection [intravenous medication] because of the infection, to stop it, it was terrible to stay there [in the hospital], but good for him, right? --- I felt terrible, I just cried. On the first days, you actually feel a lot of strength to stay there, but when you sleep 5 days in the hospital, 6 days in the hospital, you don't see anything, then you start feeling desperate. We can only hold on for [pause] [...] ah I really wanted to go home, but I couldn't just pick my daughter up and leave, because if I did that, she wouldn't be treated. After hospital discharge, the children began attending monthly outpatient follow-up appointments for clinical and laboratory evaluation. This follow-up was an opportunity for women to resignify the disease and treatment since prenatal care, and it became a double achievement: the mother and the baby's healing and the healthy growth and development of the child. --- You have to bring the baby here, right, for me to be informed and see if everything is fine with him, if it will be a problem for his development and growth, and the doctor said no. His two blood tests were negative, mine too; she said that I don't need to worry because it's not in his body. Here [reference center] I get to understand the disease better [...]. It was great, the doctor...ah she explained to me everything I wanted to know, she explained most things to me because she had more patience with me [...]. Now we are discharged, thank God. --- So, since he was born, he's been treated, so I come here [reference center]. [...] thank God the tests were negative, I'll do the last one to prove it, so thank God, God is giving a victory for me and for him too. So here [reference center] I felt calmer, because the doctor always told me that I didn't need to be afraid because she was doing very well, and she is, she doesn't have anything, she is already healed, all the exams were negative. --- DISCUSSION Our study showed the meanings attributed by women to the experience of being diagnosed with syphilis, of vertical transmission of Syphilis in pregnancy and congenital syphilis: women's experiences from the perspective of symbolic interactionism Vicente JB, Sanguino GZ, Riccioppo MRPL, Santos MR, Furtado MCC. of the disease and monitoring the child's health care, in hospital and outpatient settings. The SI framework helped understand these meanings, as it considers human behavior must be based on the social behavior, which occurs in two dimensions: the overt behavior, which is the observable external behavior, and the covert behavior, which is the internal experience of the individual . For each observable behavior during the child's health care, there is a covert behavior and, during these behaviors, the social objects of the environment are defined and redefined. In this context, women, as social actors, assumed the role of mothers, which determined their actions and the way they interpreted every moment of this trajectory. When they were diagnosed with syphilis, the women attributed a meaning to the disease , and according to SI , this interpretation is a result of their social interactions, which change through a process that is constantly developed by these women when faced with situations in their lives. The diagnosis of an STI in the life of a woman causes fear of different intensities, such as fear of death, fear of transmitting the disease to other people, or fear of social withdrawal . In our study, although the women expressed feelings of shock, concern, frustration, fear when the diagnosis was confirmed, and option for confidentiality in agreement with their partners, they did not associate syphilis with death, as they understood that, with proper treatment, there is cure and vertical transmission is prevented. The treatment of syphilis during pregnancy was interpreted as a way to protect the child and prevent vertical transmission, with feelings of frustration and defeat in case of treatment failure. The prognosis of CS is related to the severity of the intrauterine infection and the period when the woman was treated; thus, early diagnosis in pregnant women and the adoption of adequate therapy prevent vertical transmission, with children being less affected . In Brazil, the recommended treatment for syphilis in pregnant women is performed with benzathine benzylpenicillin in an appropriate dose to the clinical stage of the infection, with the first dose given up to 30 days before delivery . CS transmission is related to the quality of prenatal care, since vertical transmission can be prevented with quality care, in addition to early diagnosis and proper treatment . Several factors contribute to adequate prenatal care, including the gestational age at the beginning of the follow-up, number of visits, and routine exams. Evidence showed that gaps in this care resulted in inadequate or absent treatment in about half of the studied women . When the diagnosis and treatment of syphilis in pregnant women do not occur early, the consequences for the baby can be serious and lead to premature birth, abortion, stillbirth, and neonatal death . In primary care, nurses provide prenatal care to ensure both mother and fetus are healthy during the gestational period and heal infection and prevent vertical transmission. Nurses also talk to the women's partners, providing guidance and emotional support to both parents, often going beyond clinical issues to fulfill their social, emotional, and psychological needs . Multiprofessional teams must actively seek pregnant women who have not received prenatal care, developing actions to increase awareness of the population about the risks of unprotected sexual practice and the importance of self-care . The possibility of vertical transmission produced constant feelings in these women, such as shock, concern, and responsibility for the child's health, fear of any sign or symptom in the child, in addition to guilt and frustration. SI explains this phenomenon through social interaction , which is the central concept of the theory; then, the perception of the threat of vertical transmission stimulated the interaction of women with social objects and, during the mind activity, they attributed to CS the meaning of a consequence of their behavior and failure in their parental role, which resulted in these feelings. Similar results from other studies indicated that, when diagnosed with CS, mothers experience sadness, guilt, despair, and frustration in face of their children's pain . Prolonged hospitalization of the children and the need to undergo painful procedures for exams and treatment increased negative emotions, data that agree with studies that identified feelings of powerlessness, stress, concern, and anxiety related to multiple vein punctures, risk of death, and wait for the results of imaging and laboratory tests 15,17) . Then, nurses can identify such feelings and dedicate time to help these women cope with the disease and minimize suffering . Nurses ethically committed to comprehensive and humanized care, focused on the family, and not on the disease, can minimize the stigmatization of these women . In addition, the children's hospitalization influences the adaptation of parents, since it is a period of more vulnerability for women, who experience changes and difficult moments of selfcare and child care . In this context, nurses play an important role in supporting the development of positive parenting by promoting a connection of parents/baby/family and guiding, encouraging and enabling parents to provide responsive care to fulfill the children's needs . The women's statements indicate the meanings attributed to their children's treatment were negative experiences because they had to stay in the hospital longer than they planned and see their children submitted to painful clinical procedures, such as vein puncture for antibiotic therapy. However, guilt and pain caused by the hospitalization were relieved when they understood the disease and the value of such care for the healthy growth and development of their children, in agreement with a study that assessed the parenthood of parents of NB hospitalized with CS . This period in the hospital requires adaptation of routines, including changes in social and work life, and can generate tension and concern due to the time away from home, and away from the family and their other children . With good communication, nurses can ease the anxiety of parents and, consequently, favor the acceptance of the disease, hospitalization, treatment, and help them cope with the situation . In this context, confidentiality of the diagnosis of syphilis and CS is an important aspect, as it was the strategy found by the study participants to avoid the judgment of other people, including family members, a fact that restricts support at an important moment of building parenthood, also identified in other studies assessing CS . Sexually transmitted infections, such as syphilis, have historically led to social exclusion and prejudice, which can affect the treatment; thus, the role of nurses is essential to demystify the disease 20) . The stigma of acquiring an STI is associated of Syphilis in pregnancy and congenital syphilis: women's experiences from the perspective of symbolic interactionism Vicente JB, Sanguino GZ, Riccioppo MRPL, Santos MR, Furtado MCC. with cultural factors, considering that, for a long time, STIs were predominant among sex workers, drug users, and homosexuals. Also, it became stronger with HIV infection, which resulted in fear, shame, and rejection, and even today STIs are related to promiscuity and risky behaviors . According to data of our study, in addition to omitting the diagnosis, the women associated syphilis with HIV; they attributed to the disease a meaning of something shameful and that should be omitted to avoid the judgment of society and social exclusion. According to SI , women are always socially active, observing and identifying situations, mentally creating symbols and interacting with themselves, their families, and the environment. Thus, the situations of prejudice women have witnessed in life, combined with their current experiences, led to such interpretations. Again, nurses play an important role, providing information to resolve doubts, demystify syphilis, and allow its resignification by the women, developing a new way of acting after learning about the disease. The moment the mothers showed a better understanding of the disease was during outpatient follow-up, with acceptance of the diagnosis, perception of follow-up as essential care for the children and confirmation of healing. The Brazilian Ministry of Health recommends that children with CS should have monthly outpatient follow-up until the sixth month of life, and bimonthly follow-up from the sixth to the 18th month . To ensure follow-up of these children, the family must be included in care, meeting their needs and not just the clinical aspects of child care; thus, creating bonds would favor adherence to child follow-up . Despite the evidence reinforcing prenatal care and care after childbirth, the protocols tend to focus care on the disease and do not consider the perspective of these women's experiences, which involve feelings like pain, fear, and doubts, as expressed in the empirical material produced in this study. Provision of care can go beyond this unilateral perspective and integrate actions to listen and understand how women experience the disease, self-care, and care for their children. Our study found intense intersubjective aspects that these women experienced and resignified at different moments, from diagnosis of the disease to child follow-up in a specialized service. Their perceptions of the disease and how it affects their lives have an impact on their interactions with family, health services, and support networks. Giving voice to these experiences allows learning more about how every individual experienced and interpreted them, thus supporting nursing professionals in providing quality and comprehensive care to these patients. --- Study limitations Study limitations refer to the meanings attributed to the experience of 30 women, mothers of children with CS. Data presented in this study do not seek generalization or definitive answers, as the subjects are constantly interacting socially, decoding their experiences, and attributing new meanings to their experiences. --- Contributions to nursing Nurses have -and should assume -an essential role in care, which starts with CS prevention in primary care, and includes care provided to neonates with CS and their families in hospital environments, and follow-up care to mothers and children. Nursing interventions can empower women for self-care, and consequently, mitigate the occurrence of syphilis and reduce the number of CS cases. Nurses can help handle feelings, minimize stigmatization, support child care, and build parenthood. By understanding the intersubjective aspects involved in this experience, nurses are prepared to rethink their care practice and offer comprehensive and humanized care. --- FINAL CONSIDERATIONS This study found intense intersubjective aspects that these women experienced and resignified at different moments, from diagnosis of the disease to child follow-up in a specialized service. The diagnosis of syphilis symbolized a shock for the women, who felt responsible for preventing vertical transmission through its proper treatment. On the other hand, the diagnosis of CS represented frustration due to their efforts, in vain, to avoid vertical transmission. The symbolic meaning of syphilis was aggravated by the fear of finding stigmatizing social attitudes, especially from family members and health professionals, and was reconstructed as women acquired knowledge of the disease and how to heal it. However, guilt was expressed in different moments of having a child affected by CS -enhanced by frustration due to failed treatment and vertical transmission, and by hospitalization and painful procedures required in child care. This study highlights the importance of nurses to provide comprehensive and expanded care, going beyond clinical issues to consider social and emotional needs involved in the experience of these women and their families. --- CONTRIBUITIONS Vicente JB and Furtado MCC contributed to the conception or design of the study/research. Vicente JB, Sanguino GZ and Furtado MCC contributed to the analysis and/or interpretation of data. Vicente JB, Sanguino GZ, Riccioppo MRPL, Santos MR and Furtado MCC contributed to the final review with critical and intellectual participation in the manuscript.

Objectives: to understand the meanings attributed by women to the diagnosis and treatment of syphilis and congenital syphilis, and to outpatient follow-up of their children. Methods: this is a qualitative study conducted with 30 mothers of children with congenital syphilis using audio-recorded semi-structured interviews, which were submitted to inductive thematic analysis. Symbolic interactionism was the theoretical framework considered in this study. Results: two themes were identified, showing the maternal diagnosis involved shock, guilt, and fear of social exclusion, in addition to frustration due to failure to prevent vertical transmission. Moreover, the painful clinical procedures for the child's treatment enhanced maternal guilt, and the symbolic process of re-signification of the disease/treatment took place with the child's healing. Final Considerations: understanding the intersubjective aspects involved in this experience helps nurses rethink their care practice and contributes to their critical role in the context of syphilis.

Introduction Health facilities in low-and middle-income countries face a severe shortage of infrastructure, equipment, and drugs, which negatively impact families with low income. Several studies have emphasized the lack of resources and adequate Vikash Kumar is Assistant Professor, Department of Social Work, Northern Michigan University, Marquette, MI, USA. He can be contacted at [email protected]. infrastructure in hospitals . The procurement policy of drugs plays a crucial role in service delivery and ensuring people have access to health care at an affordable price. The unavailability of drugs, interrupted supplies, and lack of consumables pose significant barriers to the provision of health services . This, in turn, hampers access to essential medicines and disproportionately affects low-income populations, both due to the lack of drugs in public health facilities and the out-of-pocket expenses required to obtain them . Scholars have stressed the importance of strengthening local drug procurement , but it remains a challenging area. Local-level drug procurement depends on various factors. In a study on drug procurement in East Africa , Mackintosh et al. found that frontline health staff manage procurement at the local level. However, concerns arise regarding the quality of supplies from public wholesale providers, as specific drugs may not be available for over 6 months. Typically, health facility staff procure drugs from local shops and wholesalers . In another study conducted in Tanzania, Plotkin et al. evaluated the integration of HIV screening into government health facilities that provided cervical cancer services. The study revealed that while there was adequate uptake of cervical cancer screening, approximately 71% of women did not receive HIV screening due to the unavailability of HIV kits at the health facility . Logistic barriers, limited access to essential supplies and equipment, and the lack of integration may hinder the delivery of comprehensive health services. The shortage of equipment and drugs impairs the ability of health workers to provide effective care . Diagnostic and screening tools, as well as necessary consumables for health and safety, are often lacking, which directly impacts service delivery and quality of care. In addition, hospital infrastructure and resource availability are critical factors in delivering integrated care to patients. However, these aspects depend on external factors beyond the control of health workers, such as organizational policies, procedures, rules, and financial resources. This paper aims to examine the institutional process of drugs procurement in the National Program for Prevention and Control of Diabetes, Cardiovascular Disease, and Stroke . It seeks to illustrate how various guidelines, policy texts, and local practices are interconnected and affect the availability of drugs within the program at district hospital. --- Background In 2008, the Government of India launched the NPCDCS as a pilot project in 10 states: Punjab, Rajasthan, Karnataka, Kerala, Tamil Nadu, Assam, Madhya Pradesh, Andhra Pradesh, Sikkim, and Gujarat . The NPCDCS has been implemented at various levels of care, including primary, secondary, and tertiary. The program was expanded to 100 districts by merging the National Cancer Control Program into the National Rural Health Mission structure. Within this program, primary care is responsible for creating awareness, facilitating early detection, and making appropriate referrals, while secondary and tertiary care levels provide prevention, early detection, management, referral, training, and surveillance services. The integration of the NPCDCS program into the general health system aims to optimize resource utilization, ensure uninterrupted care for patients, and achieve maximum efficiency. The NPCDCS was integrated into the NRHM at both the state and district levels, leading to the establishment of district noncommunicable diseases cells in each district. Figure 1 provides an overview of the institutional structure for service provision, and Table 1 outlines the services available at different levels of care within the NPCDCS program. The primary role of the district NCD cell was to plan, implement, monitor, and evaluate program activities, while also being held accountable for achieving the physical and financial targets set by the state program. They were responsible for ensuring that these targets were met in a timely and efficient manner. However, due to a shortage of personnel within the NPCDCS program, the management and implementation of the program have been delegated to the district health society . The NPCDCS program employs various integration strategies aimed at enhancing patient outcomes through improved coordination of services. These strategies include case management, co-location of services and information, implementation of healthcare teams, and adopting a population health approach to facilitate health system integration. --- Methodology --- Methods Using institutional ethnography, this study explored how drugs are procured in the NPCDCS program in Bihar. This method of inquiry, developed by Canadian sociologist Smith, examines everyday work from the standpoint of people and how they acquire knowledge ). Institutional ethnography rejects theory and objective accounts and embraces a reflexive way of knowing the world based on our own experiences ). It offers an insider perspective that does not be subject to absolute truth, objectivity, or ideology . Institutional ethnography allows researchers to examine the multifaceted social relations that organize everyday experiences . Smith argues that texts shape the social order by conveying the interests of actors, located outside the local environment, and regulating people's everyday actions. Smith defines texts as "specific forms of work, numbers, or images that can be materially reproduced" . In Smith's perspective , the act of reading texts mirrors the standardization of work and activities across different time periods and locations. According to Smith , texts serve as the "fundamental medium for coordinating people's work activities." Building upon this concept of textual practice proposed by Smith, this study aims to analyze the drug procurement and availability in the NPCDCS program in district hospitals in Bihar. The study received ethical approval from the Institute for Global Health and Development at Queen Margaret University, with reference number REP0280. Prior to their participation in the study, all research participants provided written and verbal informed consent. --- Data Collection and Data Analysis The fieldwork and data collection for this study were carried out in three phases over a 10-month period, from November 2015 to August 2016, in three districts of Bihar: West Champaran, East Champaran, and Vaishali. In 2010-11, the NPCDCS program was introduced in Vaishali and Rohtas districts in Bihar and subsequently expanded to four additional districts: Muzaffarpur, East Champaran, West Champaran, and Kaimur, in 2011-12. The data were collected using participant observation, interviews, and reviews of official documents and program guidelines. Observations took place at various locations, such as hospitals, NCD clinics, mental health clinics, and administrative offices, to gain insights into the service provision process and the activities of health personnel in integrated health programs and service delivery. A total of 27 people who work in different roles related to the NPCDCS program were interested including health workers, program managers, hospital managers, administrators, medical doctors, etc. The selection of participants was based on their ability to provide relevant information and gain knowledge about their work in the NPCDCS program. A total of 48 official textual documents were analyzed to understand how institutional processes are coordinated at different levels. Social mapping, analytical writing, and textual analysis were used to analyze the data and examine how institutional processes affect the procurement of drugs and delivery of NPCDCS programs at the district hospitals. --- Findings Centralization and the Power of the State Government over Drug Procurement National health programs are delivered under the NRHM framework, which later included urban component and became the national health mission in India. Under this NHM framework, memorandum of understanding outlines the role and responsibility of center and state government in delivering health services across the country. These policy and program guidelines, along with various documents, such as rules, regulations, and laws, provide direction to state officials regarding the procurement of goods and services at the state and district levels. However, there is a contradiction between the memorandum of association of the State Health Society Bihar and the model generic bylaws of the state health society, which were provided by the Ministry of Health and Family Welfare at the time of signing the agreement. The Department of Health is obligated to adhere to the bylaws as part of the MoU signed between the department and the MoHFW. On the other hand, the SHSB is an autonomous organization with the authority to establish its own procurement procedures and policies as outlined in its bylaws. While the state has the power to develop its own policies related to health care service delivery, an analysis of textual documents reveals that the procurement of goods and services by the state health society is indirectly coordinated and governed by the MoHFW. According to the SHSB's MoA, the society has the freedom to "establish its own procurement procedures and use the same for the procurement of goods and services" . This highlights the autonomous nature of the SHSB, allowing it to determine its own organizational rules, regulations, and policies. However, the generic bylaws of the state health society, which are part of the MoU between the Department of Health and the MoHFW, state that "the procurement of goods and services to be financed from funds received from the Government of India [central government] shall be carried out according to the procedure recommended by the Government of India" . This implies that the state government and its agencies have limited authority over drug procurement processes if they are funded by the central government. Figure 2 illustrates the conditions related to the procurement of goods and services under the NRHM as outlined in the MoU. By signing the MoU, the state government agreed to comply with all existing manuals, guidelines, instructions, and circulars related to the implementation of the NRHM, as long as they do not contradict the provisions of the MoU itself . This MoU, being an official partnership document, imposes limitations on the authority of the SHSB and creates a dependency on the MoHFW for instructions regarding the procurement of goods and services for national health programs. As a result, it restricts the ability to innovate and address drug acquisition within the Indian states. Figure 3 provides an illustration of how the MoU indirectly coordinates and controls the procurement policy for both state and district health societies through the MoHFW's influence. A: Procurement Policy and Procedures Procurement of goods and services to be financed from funds received from Government of India shall be done as per the procedures recommended by the Government of India. In all other cases, including where the GoI allows the State a choice, following order of preference shall be applied for procurement of goods and services: Procurement of Goods: A. Rate contracts of the DGS&D, failing which, B. Rate contracts of other GoI agencies, failing which, C. Tender procedure as recommended by GOI. Procurement of services: Procedure as recommended by the GOI. The NPCDCS program in Bihar demonstrates the clear dependence of the SHSB on the MoHFW for instructions regarding the procurement of goods and services. --- The Dependence on the Central Government for Drug Procurement Led to the Supply of Substandard Quality Drugs Under the NPCDCS program, the government provides free drugs to patients with common NCDs, such as diabetes, hypertension, and cardiovascular disease, who receive treatment at public hospitals. To support the provision of these drugs, the government has allocated Rs. 50,000 per month for drug procurement for diabetes, cardiovascular disease, and stroke in each district NCD clinic, as stated in the NPCDCS guidelines . It is the responsibility of the state government to procure the necessary drugs for the NPCDCS program through the state's procurement mechanism. Table 2 in this document presents the list of drugs for diabetes, CVD, and stroke as specified in the NPCDCS guidelines. Although the NPCDCS program offers free medicines, patients are often directed to purchase their medication from local private shops. During my observation, I noticed that patients were informed about the insufficient availability of medicine for diabetes and hypertension at the district hospital. Curious about this issue, I approached a health worker to inquire about the supplies of medicine and consumables at the hospital. He responded, Do you know... in the beginning, we used to conduct diabetes screening at the NCD clinic. All the necessary supplies such as lancets, strips, and glucometers were provided by the Indian government . However, at a later point, we received a large quantity of strips that were nearing their expiration date. During that time, the nodal officer instructed us to utilize all the strips during a medical camp. We organized these camps in various locations like the local market, bus stand, and train station. However, after that incident, we stopped receiving any drugs or consumables from the government. Currently, we have to purchase everything including strips, lancets, and diabetes drugs from the local market. After gathering information from the health workers regarding the consumables provided by the MoHFW, I conducted further research and examination of official documents and letters at the District State Hospital and SHSB. These documents shed light on the procedures for the supply of consumables. The state drug storage officer raised concerns about the substandard quality of consumables procured by the MoHFW and communicated this issue to the Executive Director of SHSB through a letter. In response to the complaint, the SHSB wrote a letter to the MoHFW informing them about the substandard supply of consumables, specifically the expired strips, and seeking their advice on the matter. The MoHFW, in turn, sent a letter instructing the Department of Health to utilize all the supplied strips through health camps and fairs in the district before the expiration date. The purpose of the MoHFW's letter was to ensure that the state made use of the supplied strips through health camps. However, the letter did not address any action taken against the supplier of the substandard consumables. The focus of the instruction was solely on the utilization of the strips through health camps. It is important to note that organizing health camps is a significant undertaking at the district level, requiring careful planning and execution across districts. However, the letter did not provide any additional information about the health camps, such as human and financial resources required. It failed to address crucial questions, such as who would organize the health camps, which staff category should be deployed, and how the NCD clinic's screening services would be managed if staff were deployed to the health camps. These important questions remained unanswered. This official letter initiated a "text-reader conversation" process, requiring the administrator to take action based on the instructions outlined in the letter. Following the MoHFW's letter, the SHSB sent a letter to inform district health administrators about the utilization of the strips through organizing health camps. However, this letter also lacked information regarding the necessary resources for organizing the health camps. The district health administrator, as the reader of the letter, understood it as an administrative order that needed to be followed. In response to this administrative order, the district health administrator deployed health workers from the NCD clinic to organize health camps at various locations in the district. The purpose of these health camps was to increase awareness and provide diabetes screening services to the general public, leading to a disruption of services such as screening and counseling at the NCD clinic. Despite the efforts of the district health administrator and health workers, the utilization of the strips was limited due to a shortage of health workers, resulting in significant wastage. This situation demonstrates how the authoritative text from the MoHFW brought the SHSB, DHS, and health workers into a social relationship focused on accomplishing the task of utilizing the strips through health camps, without acknowledging or discussing the local capacity or available resources. It highlights how the work of health workers is interconnected with the MoHFW, shaping their everyday tasks and responsibilities. --- Transferring the Responsibility of Drug Procurement to the State Was not Successful Following the incident of substandard supplies, the MoHFW issued a letter instructing all states, specifically the Department of Health, to procure consumables and supplies for the NPCDCS program through the state's procurement system. This instruction immediately transferred the responsibility for procurement from the MoHFW to the state government. However, the state was unprepared to assume this responsibility, leading to unexpected delays and interruptions in procurement, as stated by the program manager of SHS. The procurement process for consumables involves various unseen tasks and activities, such as creating a list of required drugs, estimating the quantity needed, obtaining administrative approval, preparing guidelines, initiating the technical bid and tendering process, evaluating bids, and finalizing the procurement, which all require a significant amount of time. The MoHFW did not provide any guidance on how the state should ensure the availability of consumables during the transition period. It is important to note that the state program manager responsible for implementing the NPCDCS program does not have the authority to procure drugs and consumables. After delegating the procurement responsibility to the Department of Health, the Bihar Medical Service and Infrastructure Corporation Limited was assigned the task of procuring consumables for the NPCDCS program. BMSICL is designated as the State Purchase Organization and was established in 2010 under the 1956 India Company Act. It received support from the Empowered Procurement Wing of the MoHFW and technical assistance from the Crown Agent in the United Kingdom, funded by the United Kingdom's Department for International Development . The establishment of BMSICL aimed to expedite the development and streamlining of infrastructure and services in the Indian health sector. In 2005, the NRHM conceptualized BMSICL as a state-led procurement system and distribution network to enhance the supply and distribution of drugs and medicines. BMSICL serves as the sole procurement and distribution agency for goods and services for all establishments under the Department of Health, Government of Bihar. The involvement of the Crown Agent UK included training, needs assessment, development of procurement procedures and systems, storage management, quality assurance, and information management. The establishment of a centralized procurement agency for the state aimed to bring transparency to the procurement process. Figure 4 provides an overview of the coordinated efforts to establish a state procurement system in Bihar. Despite the efforts to promote transparency and efficiency in the procurement of goods and services, BMSICL, in 2014, faced allegations of corruption. The Department of Health discovered that BMSICL had purchased substandard drugs and medical supplies from a blacklisted company at exorbitant prices . In response to these findings, the government took action by suspending senior health officials and initiating an inquiry into the corruption charges. The suspensions at BMSICL had a significant impact on drug procurement in Bihar. Between April and May 2015, BMSICL issued a short-term tender for the supply of life-saving drugs. However, this tender did not attract suppliers or pharmaceutical companies to participate in the bidding process. Out of the 25 required drugs, BMSICL received only one bid for 23 drugs, which was subsequently rejected on technical grounds . According to the Bihar Financial Rule 2005, a single bid cannot be accepted for procurement decisions . This corruption incident had a wide-reaching impact, affecting procurement for all health programs in Bihar. During a discussion with a state program manager, he expressed frustration with BMSICL for the delayed procurement of consumables for the NCDs programs, ...However, the BMSICL officers do not listen to us. Despite sending numerous letters to the Managing Director of BMSICL, we have received no response to our requests. We have been specifically requesting the rate contract so that we can inform the district health administrators to procure goods at the rates finalized by BMSICL. In the interview, the health official expressed his concern about the unexpected delay caused by BMSICL. Despite his efforts to draw attention to the procurement of drugs and consumables for the NPCDCS program, BMSICL did not respond to his requests. This delay in BMSICL's actions had a significant impact on many health programs in Bihar, as noted by the manager at SHSB. The frustration resulting from these delays was also observed during discussions with health workers at NCD clinics in the study sites. The health workers felt helpless when they were unable to provide medication to financially disadvantaged patients at the NCD clinic. These experiences of frustration and helplessness stemmed from broader institutional inaction. Until August 2016, BMSICL had not established the procurement rates for consumables such as strips, lancets, and drugs. This further hindered program implementation and service delivery. In the absence of a response from BMSICL, the SHSB issued instructions to the DHS, urging them to procure drugs and consumables for health programs at the district level, following the Bihar Financial Rule 2005, until further orders were received from the SHSB. --- Drug Procurement at the District Level The district hospitals responsible for implementing the NCDs program faced a shortage of essential drugs for patients with common NCDs. As a result, patients were required to purchase drugs and medicines from private shops, leading to increased out-of-pocket expenses. Although drugs were purchased in smaller quantities to address immediate patient needs, it proved insufficient. A health worker mentioned a "local purchase system" that enables district administrators to procure drugs without being burdened by administrative and bureaucratic processes. During an interview, a health worker expressed: Since the government, specifically the MoHFW, has ceased providing us with medicine, we resort to procuring it through a "local purchase" system. In most cases, the account manager provides us with funds to purchase lancets, strips, and medication for diabetes and hypertension. We buy medicine on a weekly basis, adjusting the quantity based on consumption levels. On one occasion, when I informed a nodal officer about the lack of drugs at the NCD clinic, he personally contributed Rs 5,000 [$71.4] and instructed me to utilize the money immediately to acquire the necessary medicine and consumables. The health worker shared his experience with the drug procurement process, highlighting the recurring issue of medicine shortages at the NCD clinic. The manager clarified that "local purchase" refers to procuring goods from local shops without engaging in a bidding or quotation process for purchases below Rs 15,000 . Upon further investigation, I discovered that the manager's description of "local purchase" aligned with a specific financial rule. Rule no. 131C of the Bihar Financial Rule 2005 specifies that goods can be procured up to Rs 15,000 without the requirement of inviting quotations or offers. The rule states, Rule 131C. Purchase of goods without quotation: Purchase of goods up to the value of Rs. 15,000/- only on each occasion may be made without inviting quotations or bids on the basis of a certificate to be recorded by the competent authority in the following format. "I, ___________________, am personally satisfied that these goods purchased are of the requisite quality and specification and have been purchased from a reliable supplier at a reasonable price." Rule 2005) The Bihar Financial Rule 2005 is a set of guidelines that governs the procurement of goods and services by government departments. Table 4 outlines the procurement process and requirements specified in the rule. The "local purchase" process has been implemented to reduce administrative and bureaucratic involvement, as stated by the manager from the DSH. This system allows for flexibility in procuring medicine and drugs based on local needs. However, I discovered that managers were hesitant to purchase large quantities of medicine and consumable supplies due to a shortage of health workers in the NPCDCS program. One manager expressed the following concern: There is no point in buying strips and drugs in large quantities because only a few staff members are working on the programme [NPCDCS]… Who will distribute the drugs and who will manage the programme? If something goes wrong, then who will be responsible and be held accountable? The manager expresses concerns about the additional responsibility and accountability that comes with procuring large quantities of consumables. They highlight the potential challenges of drug distribution and the risk of wastage due to a shortage of staff. On the other hand, health workers believe that alternative mechanisms, such as involving hospital pharmacists or maintaining proper distribution records, can ensure transparency and accountability in the process. However, these discussions around accountability and transparency overshadow the concern for patient affordability. It's important to note that medical drugs and consumables are regulated goods, and their procurement should ideally be supervised by qualified authorities. In contrast, health workers in the NCDs program receive cash to purchase medicine from the local market, as described in an interview with one of them. Sometimes, the nodal officer provides us with money to purchase drugs and medicine. We take the money and buy them from a local private medical shop. If we feel that we don't have enough medicine and consumables, we inform the nodal officer about the situation. In response, the nodal officer sometimes gives us money and instructs us to submit the bill to the account manager. At times, we visit the DHS office where the accountant provides us with the necessary funds to buy medicine. This is the process we follow to procure medicine. Health workers are regularly involved in the procurement process of drugs and medicines at the local level. They follow a sequential series of actions, including assessing the weekly requirement, informing the nodal officer, coordinating with the account manager, visiting the DHS office, receiving funds for procurement, visiting the local market to purchase medicine and consumables, coordinating with nodal officers for approval and signing of receipts, submitting the receipts to the accountant at the DHS office, maintaining procurement records in an inventory register at the NCD cell office, and informing other staff members about the availability of drugs for distribution. The involvement of health workers in procurement is based on decisions made by managers, guided by official texts such as the Bihar Financial Rule 2005, the MoU, and NPCDCS guidelines 2013. However, these texts lack specific information to guide officers in making informed decisions. Some gaps in the texts include who should procure drugs from the local market, criteria for selecting shops and suppliers, and the required knowledge and understanding of the person involved in the purchase. To address these gaps, managers interpret the official documents and engage in a text-reader conversation to form their own understanding. They align their actions with the conditions outlined in the official documents. Due to the lack of clarity in the texts, managers involve NCDs program health workers in the procurement process, allowing hospitals to provide free medicine to patients. However, this involvement significantly affects the primary work of health workers in the NCD program, such as providing counseling services to patients with common NCDs. Health workers often spend time coordinating with managers and nodal officers for procurement and may even need to convince managers to urgently procure medicine or consumables. While managers and administrators are responsible for procurement, involving health workers in administrative tasks like purchasing drugs detracts them from their primary role of providing healthcare services. The regulatory texts provide guidelines but do not address the impact on service delivery caused by gaps in the text. This situation allows managers to manage health workers without considering the consequences on service delivery. --- Discussion and Conclusion Scholars have argued that a centralized procurement system can lead to cost reduction, improved efficiency, and increased transparency and accountability in procurement procedures . However, this study reveals that the centralized procurement system can be influenced by local factors, such as corruption in purchasing organizations and the supply of substandard drugs. Despite the establishment of a specialized drug and procurement organization, namely BMSICL, to promote transparency and accountability, the organization failed to procure drugs for over 3 years. The availability of drugs and supplies is considered a crucial factor for the success of integration . Insufficient availability of drugs in health facilities also increases out-of-pocket expenses for patients . The findings of this study align with previous research , indicating that despite the provision of free medicine for common NCDs, most patients still purchase drugs from private health care providers. At district hospitals, drugs are often procured in small quantities to minimize administrative work. However, this approach fails to meet the demand for drugs in these hospitals. The Bihar Financial Rule 2005, a standard text for procurement of goods and services in Bihar, only outlines the procurement procedures such as local purchase, quotation, and tender. It does not specify which cadre of health workers or managers should be involved in the drug procurement process. As a result, local managers and officers are left to interpret the rule and find ways to navigate the procurement process. Increasing administrative support and implementing large-scale procurement at the district level could ensure drug availability for the NPCDCS program. The study highlights the influence of various institutional and regulatory texts that shape the implementation of integrated programs in district hospitals and carry the authority and instructions of the MoHFW. While these health societies were intended to be autonomous, the study reveals that their governance, decision-making, and autonomy were restricted through textual practices, despite their legal entity and autonomous status. This study contributes to the social development and health system literature by illustrating how procurement at the central, state, and local levels is influenced by multiple factors. It emphasizes the need for policymakers to carefully consider the formulation of policies and examine how they are interpreted and utilized. The involvement of managers and officers in engaging frontline health workers in drug procurement, which goes beyond their job description, ensures drug availability but can temporarily disrupt service delivery at district hospitals. --- Ethical Statement Before commencing the fieldwork, ethical approval for the study was obtained from the Institute for Global Health and Development at Queen Margaret University, with reference number REP0280. Written and verbal informed consent was obtained from all research participants before their involvement in the study. --- Declaration of Conflicting Interests The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

India has the largest number of families living below the poverty threshold, resulting in high out-of-pocket expenditure for healthcare, including essential medicines for noncommunicable diseases (NCDs). With the increasing prevalence of NCDs, the role of the Indian government becomes crucial in ensuring that patients have access to essential drugs through public health facilities. This research paper explores the institutional processes of drug procurement in the National Program for Prevention and Control of Diabetes, Cardiovascular Disease, and Stroke in Bihar, India, using institutional ethnography as its methodological approach. The data for the study was collected over a 10-months period in three districts of Bihar and involved collecting data through participant observation, interviews, and reviews of official documents and program guidelines. The findings highlight the influence of various institutional and regulatory texts that shape the implementation of integrated programs in district hospitals and carry the authority and instructions of the Ministry of Health and Family Welfare. Despite their legal entity and autonomous status, the study reveals that the governance, decision-making, and autonomy of health societies involved in the program were restricted through textual practices. The study's contribution to social science and health system literature lies in illustrating the multiple factors that influence drug procurement at the central, state, and local levels.

Introduction For older adults, the important relationship between social resources and physical and mental health outcomes is well established [1][2][3][4][5]. However, as the proportion of oldestold adults in the USA increases, particularly centenarians, and more research attention is given to their study [6,7], theoretically driven investigations of resources necessary for adaptation to changes associated with advanced age are required [8,9]. Levitt [10] reviewed work focusing on social development across the life span and recommended the social convoy model as a general or unifying model. In addition, Seeman and Crimmins [11] conducted a review focusing on the effects of the social environment on health and aging from the perspective of both epidemiology and demography. Based on their extensive literature review, including the early work of Antonucci and Jackson [12], they posited a biopsychosocial model of health and aging that included the influence of structural and functional assessments of social relationships on physical and mental health outcomes through psychological characteristics such as self-efficacy. Recently, Antonucci et al. outlined suggested modifications of the original convoy model of social support based on two decades of empirical and theoretical studies . Their social support-efficacy model posits a specific mediator, self-efficacy, through which social relations influence health outcomes. In addition, Antonucci et al., as well as Seeman and Crimmins [11], emphasized that situational or contextual experiences are considered important influences on the association among social relations, selfefficacy, and health outcomes for older adults [13]. --- Mental health --- Self-efficacy --- Social provisions --- Physical health Social resources Figure 1: The study's conceptual model was based on the theoretical work of Antonucci et al. [13]. For very old adults, residential setting , one assessment of contextual experience, is very salient to the constructs of the support-efficacy model [14][15][16]. Long-term care is often needed by older adults. It is estimated that by 2050, the total number of individuals subscribing to paid long-term care, whether at home or in some type of residential care, will likely double from 13 million in the year 2000 to 27 million [17]. According to a 2009 report by The National Center for Assisted Living, more than 900,000 adults, whose average age was 86.9 years, resided in assisted living facilities [18]. Regarding nursing home care, researchers found that the number of individuals receiving such care, on any given day, rose from 1.28 million in 1977 to 1.63 million by 1999, a 27% increase [19]. Bowling and Grundy reviewed literature focused on the association between older adults' social resources and mortality in population-based longitudinal studies [20]. They found substantial evidence for the relationship between social support, social network structure, health status, mortality, and likelihood of entry into institutional care. Regarding the moderating role of residential status, empirical research has demonstrated that measures of social relations, including structural and functional assessments, differ across residence status [16,20]. Thus, the current study's purpose was to specify and test a version of Antonucci and colleagues' [13] mediating model using cross-sectional data from participants in the Georgia Centenarian Study [21] who resided in three distinct living environments: private homes, assisted living facilities, and nursing homes. Close social relationships received much attention in the literature over the past decades both from a theoretical [13,22,23] and empirical [3,[24][25][26] perspective resulting in strong evidence that older adults with high levels of social resources enjoy better health than those lacking in close relationships. Convoy, according to Antonucci et al., depicts the close relationships that surround an individual and promote positive development [13]. Social relations, a term often used to define and identify convoy relationships [24], may be operationalized to encompass social networks and social support [27]. Structural assessments of convoy members include measures of network size, member type , network members' geographical propinquity, and frequency and type of contact with network members. Functional assessments address the question of what type of support network members provide [28], such as instrumental or emotional support. Krause [29] reviewed over a dozen different types of support from the literature. The current study included both structural and functional assessments of social relations in the tested model. The literature calls for investigations of mediating mechanisms through which social relationships influence health outcomes, in particular assessments of self-efficacy, human agency, mastery, competence, and control [13,30]. Conceptually, perceived control over one's life events and conditions is closely related to various measures of competence such as internal locus of control, mastery, and selfefficacy [2,24,31]. According to Ross and Sastry [32], perceived control may tap the same underlying construct as self-efficacy. Over time, contact with significant members of one's social network and the different types of support provided may increase an individual's sense of worth and ability to influence the situational environment. This study featured a measure of self-efficacy, competence as measured by the NEO PI-R [33,34], as the mediating mechanism through which social relations influenced health outcomes. The competence facet, from conscientiousness, addresses how capable or effective an individual feels. The current study extended the literature by investigating the support-efficacy model with very old adults and by examining the moderating influence of living environment . Bowling and Grundy challenged researchers to consider influential variables that need to be controlled and intervening variables that might explain such associations [20]. Our analyses controlled for sex, education, perceived economic sufficiency, and instrumental activities of daily living in our analyses [35,36]. Based on the literature describing the various reasons for residing in a private home, an assisted living facility, and a nursing home , we hypothesized that the model would fit the data uniquely for each subsample because the living environments and the contextual situations of the participants influence their physical and mental health differentially [37][38][39][40]. How the relationships between the models' variables differ by residence status was a research question we investigated. --- Method 2.1. Participants and Procedures. Data for this study came from a Georgia population-based sample of centenarians and octogenarians collected between 2002 and 2005. The sample, comprised of adults aged 98 years and older, was based on a census from a 44-county northern Georgia region including all skilled nursing and personal care facilities. In addition, registered voter lists and corroborating birth date information was also used to identify participants in that region. A refusal to participate rate was not possible to estimate due to the complexities of the sampling strategy. Of the estimated 1244 eligible centenarians in the population, 19.2% participated, whereas 135 who declined to participate were found to be age eligible. Thus, an effective response rate has been estimated at 63.9% and nonresponders were very similar in terms of certain demographics to final participants. Also, no substantial differences in cognitive status were expected as the sampling strategy included sufficient participants from institutional settings. The Georgia Centenarian Study, Phase 3 investigated factors related to survival and functioning of centenarians. Further details on the study's sampling, data collection, and design are provided by Poon and colleagues [21]. Thus, 158 cognitively intact, community-dwelling, or institutionalized near-centenarians and centenarians were included in this study. Of the participants, 78.5% were female, 85% were White and 15% Black, and 85% were widowed, whereas only 6% were married. --- Measures --- Control Variables. Analyses controlled for participants' sex, mental status, activities of daily living, education, and perceived economic status. For sex, males were coded "0" and females "1." The Mini-Mental Status Examination was used to control for cognitive ability ; higher scores indicated greater ability. Two commonly used subscales, instrumental activities of daily living , and physical activities of daily living were combined to create the self-care capacity assessment, activities of daily living . An example of a question asked included "Can you do your housework?" and was scaled so that 2 = without help , 1 = with some help , or 0 = are you completely unable to prepare any meals? Cronbach's alpha for this measure was .88, and it was scaled so that higher scores indicated higher levels of self-care capacity. A single question from the OARS [42] "How well does the amount of money you have take care of your needs?" was used to assess the participant's financial situation . This was scaled from 1 to 3 . --- Dependent Variables. Research has validated a singleitem measure of self-rated physical health as a summary assessment of overall health status, predictive of outcomes such as mortality, BMI, physical activity, and hospitalization among others [43][44][45]. DeSalvo and colleagues [46] compared the predictive accuracy of a single-item measure of general health with multi-item scales . They found the single item performed as well as the multi-item measures regarding validity and reliability, in addition to saving time and money over the use of longer instruments. We used an item from the OARS [42] physical health section asking "How would you rate your overall health at the present time?" Responses ranged from 0 to 3 . Similar to physical health, numerous studies have employed a global self-rating of mental health [47,48]. We assessed self-reported mental health with an item from the OARS [42] asking "How would you rate your mental or emotional health at the present time?" Responses ranged from 0 to 3 . --- Predictor Variables. Two commonly used measures for assessing social relations among older adults were included in this study: The Social Provisions Scale and social resources [42]. We employed a 12-item short form of the SPS, a functional assessment that asked questions such as "I have close relationships that provide me with a sense of emotional security and well-being" and "There is no one I can turn to for guidance." Items were scaled from 1 to 4 ; Cronbach's alpha for the scale was .75. Higher scores reflected higher levels of social provisions. Social resources, a structural assessment of social relationships, was measured using one question from the OARS [42]. In particular, this question asked "How many times during the past week did you spend some time with someone who does not live with you; that is you went to see them or they came to visit you, or you went out to do things together?" Responses were coded 0 = not at all 1 = once 2 = 2-6 times and 3 = once a day or more. Based upon work previously conducted [16] with this measure and very old adults , we selected a question tapping frequency of network contact because physical limitations common with very old adults [50,51] often limit phone or other communication-only contacts and reduction in network size due to mortality-by definition centenarians have outlived peers, spouses, and often children-limits the numbers of individuals in their network. In addition, due to constraints composed by socioemotional selectivity [23], we did not use questions from the social resources section of the OARS asking about the number of phone conversations or number of network members participants knew well enough to visit as very old adults have likely reduced the number of network contacts to the few most salient. Thus, we selected the question above to tap the amount or frequency of contact the participants had with network members in the past week to comprise our structural measure of social relations. --- Mediating Variable. The NEO PI-R [34] is a widely used measure that captures participants' impressions of their own personality along the Big Five personality dimensions. Self-efficacy includes an individual's belief in his/her own competence to successfully perform a particular action [31]. In the present study, the competence facet from conscientiousness was used because it taps the degree to which a respondent feels capable and effective. Feeling well prepared to face life and its changes is typical of those who score high on this facet, and the facet is often highly correlated with self-esteem and internal locus of control [34]. Seven items comprised this facet and were scaled from 0 to 2 ; Cronbach's alpha for this facet was . 70. Descriptive statistics for each of the study's variables, by residential status, and one-way ANOVA's comparing the means across residential status, are provided in Table 1. --- Data Analytic Procedure. Because previous investigations [16] revealed significant differences in social resources and social provisions between octogenarians and centenarians living in private homes and among centenarians residing in private homes, assisted living facilities, and nursing homes, we conducted our analyses by subgroup. Based upon Antonucci and colleagues' model [13], we tested a path analytic model for each subgroup. We used path analysis for a number of reasons. First, because of our limited sample size, we employed manifest rather than latent variables to reduce the number of parameters estimated in our models. Second, if necessary, we also wanted to test for model equivalency across our subgroups. Third, our hypotheses called for tests of directionality with self-efficacy as a mediating mechanism. Working with very old adults presents numerous challenges, one of which is locating and assessing participants who often present with numerous hearing, visual, and other medical conditions, in addition to mortality concerns over time [7], resulting in smaller sample sizes. The literature on sample size and covariance structure modeling has addressed the concern of sample size and the number of parameters estimated [52][53][54]. Jackson concluded that when small sample sizes are encountered, assessments of model fit such as chi-square goodness-of-fit and RMSEA, for example, are most sensitive to misspecification and therefore, recommended. In addition, Herzog and Boomsma conducted a Monte Carlo study demonstrating that Swaincorrected estimators were robust to small sample sizes and recommended their use for small sample size research [52]. We used their syntax for use with R software for each of our final models presented in the Section 3 below, and no differences in fit were found between what we reported and the Swain-corrected estimations. Thus, a path model allowed us to examine model fit, model equivalency between groups, and indirect effects through the mediating mechanism of self-efficacy. The literature on multiple-sample testing in structural equation modeling argues for establishing a baseline or bestfitting model for each sample first [55]. Kline extends the point and argues that unless an unconstrained model fits well across samples, it makes little sense to test additional constraints [56, page 295]. We first specified and tested the hypothesized support-efficacy model, determining the best model fit for each subgroup . Analyses were conducted with Mplus Version 5.0 [57] using full-information maximum likelihood to handle missing data; overall model fit was assessed by employing the Satorra-Bentler chi-square test statistic that is robust to nonnormality of measures, referred to as the MLR χ 2 in Mplus. Model evaluation was based on the chi-square goodness of fit test and other fit indices: the comparative fit index-CFI [58], root mean squared error of approximation , and the standardized root mean squared residual . Values close to .95 for CFI, .08 for SRMR, and .06 for RMSEA suggest that good fit between the observed data and the hypothesized model exists [60,61]. Nested model testing was conducted according to the procedure outlined in Mplus [57]. Control variables included sex, mental status, perceived economic sufficiency, and activities of daily living. --- Results --- Centenarians in Private Homes. A base model with no degrees of freedom was tested. The regression of mental health on social resources was not significant, , neither was the regression of mental health on self-efficacy . These paths were deleted, and the nested model fit the data well: MLR χ 2 = 2.36, P = .31, CFI = .99; RMSEA = .04; SRMR = .02. In this model, all specified paths were significant ; however physical health regressed on social provisions was the weakest path. Thus, for the sake of parsimony, we specified a model without this path: MLR χ 2 = 5.14, P = .16, CFI =.97; RMSEA =.08; SRMR =.03. We conducted a nested model test according to L. K. Muthén Muthén [57]; this model's fit was not significantly different from the model with the path regressing physical health on social provisions: Δχ 2 = 2.50, P = .11. The final model depicts the most parsimonious, best fitting model to our data following the support-efficacy conceptualization for centenarians residing in private dwellings. Direct effects for social resources on physical health and social provisions on mental health were found in the previous model, whereas in this best-fitting model for centenarians in private homes, no direct effects for social resources on mental health or social provisions on physical health were found. However, consistent with Antonucci and colleagues [13], indirect effects operating through self-efficacy were found both for social resources and social provisions on physical health , whereas no indirect effects were found for either predictor on the outcome mental health. --- Centenarians in Assisted Living Facilities. In the base model, significant predictors of physical health and selfefficacy were found; no predictors were found for mental health. Physical health was predicted by social resources and self-efficacy by social provisions . Based on these results we tested a model deleting the path of social provisions predicting physical health, social resources predicting self-efficacy, and the predictors of mental health except controls. This model fit the data adequately: MLR χ 2 = 8.93; P = .11; CFI = .91; RMSEA = .12; SRMR = .06. However, in addition to the higher value for RMSEA, one of the modification indices looked promising for the regression of mental health on self-efficacy, so we tested a model including this path. This model fit the data well: MLR χ2 = 5.29, P = .26, CFI = .97; RMSEA = .08; SRMR = .04. The nested model chi-square test was significant . We selected the latter model over the former because the Chi-square and the CFI, RMSEA, and SRMR indices suggested that it was the better fitting model than the nested model with more degrees of freedom . In addition, we conducted the tests of indirect effects from social provisions to both physical and mental health. The indirect effect on physical health was not significant , whereas the indirect effect from social provisions on mental health through self-efficacy reached significance for a hypothesized effect . --- Centenarians in Nursing Homes. The base model used in previous analyses could not be tested because the covariance coverage fell below 10 percent . Inspection of our individual variables led us to delete our measure for economic sufficiency. In addition, when this model was run, difficulties were encountered estimating appropriate standard errors based on the control variable sex. Of the 105 centenarians living in nursing homes, 92 were female and 13 male. Thus, further models for centenarians in nursing homes excluded economic sufficiency and the control variable, sex. No further estimation difficulties were encountered. In the tested base model, neither exogenous predictor, social resources nor social provisions significantly predicted self-efficacy. However, both self-efficacy and social provisions significantly predicted mental health, whereas only social provisions approached statistical significance predicting physical health . Regarding the magnitude of the standardized beta for social provisions, Jöreskog [62] noted that it is possible for a standardized coefficient to be greater than one and that it does not necessarily imply error in the model. However, he did point out that such a finding likely points to multicollinearity in the data. Our measure of ADLs was negatively and highly correlated with social provisions in this model. Thus, we deleted ADLs from the analysis and found that indeed social provisions significantly predicted physical health , neither measure of social resources predicted self-efficacy, and only self-efficacy predicted mental health . In this model, R 2 for physical health was .29; for mental health it was .19, and for self-efficacy it was .84 . In addition, both mental status and education were significant predictors of self-efficacy. Thus, as a supplemental analysis, we computed a model specifying the indirect effect from these control variables to mental health through self-efficacy. The standardized indirect effect was .49 . --- Discussion This study tested the support-efficacy model [13] for each of three centenarian groups participating in the Georgia Centenarian Study [21]: centenarians residing in private homes, centenarians residing in assisted living facilities, and centenarians residing in nursing homes. A focus of the model is the hypothesized indirect effect of social relations on health outcomes of older adults through the mediating mechanism of self-efficacy. Overall, the study's results supported the hypothesized model. The mediator, self-efficacy, completely mediated the influence of social relationships in two of the three models tested on self-report data from centenarians . In particular, how the model worked varied by residential status ; the relationship among the variables for the best fitting model was different for each residential status. Three findings, consistent across the three models, merit discussion. First, our results supported the hypothesized positive influence of social relationships on the physical and mental health of centenarians. These findings are consistent with previous research across the life span [20,63,64]. However, ambivalent findings about the valence of social support on psychological outcomes have been reported. For example, perceived support is often beneficial whereas actual received support may be detrimental [65,66]. We believe our study's positive findings for the influence of social relations on health outcomes for centenarians, regardless of living environment, are best explained by considering the qualitative work of Chen et al. [37]. They developed a grounded theory of elders' decisions to enter assisted living facilities, including the weighing and balancing of gains and losses "to go where the help is" -the anticipated outcome of moving. When losses outweighed gains, they went to the help; they moved to a facility. Such a move often includes cognitive, affective, and physical stressors. Often, a move is perceived as loss of independence and is not preferred to the private home, but is preferred relative to entering a nursing home [38,40,67]. These decisions and associated stressors also apply when moving from an assisted living facility to a nursing home. We believe that it is possible that centenarians in our study understood the salubrious role social relations provide for their independence and ability to live in a private home setting; such support either delays the need to move toward help or for those no longer able to remain in a private home, such support could be effective in the transition from private home to assisted living facility. Thus, the direct and indirect effects of social resources and social provisions were positively associated with the mental and physical health of our very old participants. A second finding, for centenarians in private homes and for centenarians in assisted living facilities, consistent with the model and previous research differentiating between the effects of social network and social support variables, is the strong influence of social provisions, compared to the influence of social resources, primarily on outcomes of well being [36,68]. Our assessment of social relations tapped the frequency of contact between participants and their network of friends and family, whereas Cutrona and Russell's Social Provisions Scale [49] was designed to assess the type of support provided by others. Because social provisions were self-reported by participants, the measure likely included their perceptions of available support [69,70]; it does not necessarily assess support actually provided. We believe that the Social Provisions Scale, with its breadth of functional supports assessed, tapped the appropriate support needed by our participants for the particular stressor experienced, resulting in a strong relationship between the measure and both physical and mental health. Consistent with the hypothesized model and the literature regarding mediation through self-efficacy, was a third noteworthy finding: the mediating role of self-efficacy between social relations and the health outcomes for centenarians in private homes and assisted living facilities. Intriguingly, for centenarians in assisted living facilities, the influence of social provisions was completely mediated through self-efficacy. The effect on mental health reaches statistical significance for a one-tailed test; the effect on physical health approaches statistical significance for a onetailed test. Cutrona and Russell [49] provided an explanation about the theoretical underpinnings of their Social Provisions Scale that helps explain this finding. Theoretically, both Bandura [31,71] and Cobb [72,73] predicted that social support should lead to an individual's self-assessment of confidence or competency. Such assessments of self-efficacy in turn encourage individuals to attempt difficult tasks, work harder, and persist when facing difficult situations. Thus, greater levels of self-efficacy could lead to more effective coping and higher levels of physical and mental health. Centenarians in assisted living facilities are surrounded by potential supporters and provisions that are available if needed and called upon [37]. Also, they are not in private homes where they could be isolated or distant from support and they are not in nursing homes where chronic physical and mental health concerns are often experienced. These very old adults, residing in an assisted living facility, may be in the best of situations: they are independent in terms of most if not all activities of daily living and, if needed, social resources in terms of network members' availability and social provisions are close at hand. Additionally, Holahan et al. [74] proposed and tested a mediation model that posited the indirect effects of social resources on psychological adjustments through personality characteristics such as self-confidence. They found that in situations of high stress the indirect effect model fit the data, whereas in lower stress situations, direct effects were found. It might be that centenarians in our study have been in assisted living facilities for a lengthy period of time and were facing the stressful move to a nursing home. Either explanation of the results fits with the particular effectiveness of the support-efficacy for this group of older adults. In support of this explanation for centenarians in assisted living facilities, the hypothesized mediating model explained the most variance in both outcomes, mental and physical health , compared to the models tested for centenarians in other living situations. Three unique findings of the current study for centenarians in private homes were noted: the influence of social provisions on physical health was completely mediated through self-efficacy, whereas it was not for mental health, the influence of social resources on physical health was partially mediated through self-efficacy, and social resources did not influence mental health directly or indirectly; only social provisions directly influenced mental health. Centenarians in private homes are truly expert survivors [75], and while not necessarily healthy as compared to younger adults, they are likely autonomous individuals [76]. The complete mediation of social support or functional helps through self-efficacy hints to the fact that "learned helplessness" has not become the norm for these individuals. Either they are receiving very appropriate support that does not undermine their self-confidence or they perceive support that exists if they need it. Bandura [31] referred to efficacy expectations or beliefs that one can do or perform particular actions, a belief about personal competence [77]. Once again, the literature addressing why older adults transition to assisted living facilities or nursing homes provided insight into the probable reasons for this mediated path. One factor related to relocation is the need for help with activities of daily living and medication management [78]. Perhaps, for this group of centenarians living in a private home and experiencing higher levels of independence than their peers in assisted living facilities or nursing homes, the frequency of contact with social network members and the particular types of support provided by others' assistance enables them to feel competent or capable of accomplishing the tasks necessary to remain in their residential setting, leading to perceptions of better physical health. In addition, these participants could be healthier than those not residing in private homes. Thus, whatever supportive relationships were in place and active helped the centenarians to maintain a level of physical health concomitant with independent living and associated feelings of self-efficacy. As mentioned above, the work of Holohan et al. [74] demonstrated that indirect effects of social support through personality characteristics such as self-efficacy operated primarily under stressful conditions. It may be that centenarians living in private homes will finish their years in a private setting, at least until near the end of life when their physical health begins to precipitously fail. Perhaps private home dwelling is associated with lower stress levels, thus explaining the direct influence of social provisions on their mental health, and why, regarding their physical health, which is necessary for dwelling in a private home, both direct and indirect influences of social relations were operative. In addition, we believe that this line of thinking may be one explanation for the lack of influence on mental health by self-efficacy either directly or as a mediator; the strong, direct influence of social provisions overrode the influence of the participants' personal perspective of their own mastery. Likely, the stress is low in the presence of such supportive help as centenarians living in private dwellings do so with support from others. When that support is perceived to be available or present, it likely contributes more to their mental health than their own perception of self-efficacy. For centenarians residing in nursing homes, selfefficacy's lack of association with physical health is a unique finding. Once one resides in a nursing facility, it is likely that a strong sense of self-efficacy is not helpful or advantageous over outcomes where one has minimal influence such as physical health [76]. However, instrumental and received social support are concomitant with nursing home residence and likely explain the direct effect of social provisions on physical health. As mentioned in the results section regarding the supplemental analyses, we did find a strong indirect effect of mental status and education on mental health through self-efficacy. In addition, we mentioned the strong association between social provisions and activities of daily living. Consequently, we deleted activities of daily living from the model because of multicollinearity. These findings agree with a recent meta-analysis of 77 reports based on longitudinal data from community-based samples. It found the strongest predictors of nursing home admission included functional disability, cognitive impairment, and prior nursing home use [14]. At this stage of the life span and in this residential setting, there is likely little centenarians can do regarding their physical health, other than utilizing the direct services of others. However, participants who have higher levels of cognitive ability tend to have higher levels of self-efficacy and in turn higher levels of mental health. This discussion may also provide an explanation regarding the influence of self-efficacy on mental health for centenarians residing in nursing homes. Whereas, for those in private homes, perception of self-efficacy was not found to influence mental health-social provisions tended to directly and Journal of Aging Research significantly influence their mental health-for centenarians in nursing homes, perception of self-efficacy mattered. For participants with higher levels of cognitive ability, what they might have control over is how they view their lives or their mental outlook on life [1,75,76]. Our study is not without limitations. First, we examined three distinct groups of centenarians based on residential living status resulting in relatively small sample sizes. Second, our study was cross-sectional in nature; it did not follow very old adults from dwelling in a private home to an assisted living facility, and ultimately to a nursing home, nor was the study able to assess change in the measures over time as proposed by Antonucci et al. [13]. Centenarian studies face difficult design issues because the remaining life expectancy of participants is often less than two years depending upon birth cohort. In addition, we do not know if our participants were in the nursing home for the second or third time with intervals back in private residences or assisted living facilities. Gaugler and colleagues [14] found prior nursing home use to be one of the strongest predictors of nursing home admission. Third, measurement concerns regarding multiple assessments and types of reporting for the constructs studied would reduce possible bias in the results. These limitations provide opportunity for future research to build and expand upon the study and the theoretical model. The present study added to the existing knowledge base of very old individuals by specifying and testing a version of the support-efficacy model [11,13]. In addition, we considered a key situational characteristic of very old individuals near the end of the life span as a moderating influence: residential status . The study affirmed the specified relationships between variables of the model; however, specific to this study was the finding that the hypothesized model uniquely fit each group of participants. Future work with very old individuals will be aimed to consider and account for the moderating influence of residence status on the constructs examined: social relations, self-efficacy, and both mental and physical health. --- Submit your manuscripts at http://www.hindawi.com --- Stem Cells International Hindawi

We investigated the influence of social relations on health outcomes in very late life by examining the support-efficacy convoy model among older adults who resided in three different residential environments (centenarians in private homes, n = 126; centenarians in assisted living facilities, n = 55 ; centenarians in nursing homes, n = 105). For each group, path analytic models were employed to test our hypotheses; analyses controlled for sex, mental status, education, perceived economic sufficiency, and activities of daily living. The hypothesized relationships among the models' variables were unique to each of the three groups; three different models fit the data depending upon residential environment. The direct and indirect effects of social relations assessments were positive for the mental and physical health of very old adults, suggesting that participants welcomed the support. However, residential status moderated the associations between the assessments of social relations, self-efficacy, and both outcomes, physical and mental health. * Private homes differed from nursing homes, P < .05; * * Private homes and assisted living facilities differed from nursing homes, P < .05; * * * Each was significantly different from the other, P < .05.

Introduction Interpersonal and institutional racism take an unconscionable toll on the mental health of Black Americans, and existing health disparities have been magnified by the strain of the COVID-19 pandemic and ongoing epidemics of police violence and public intimidation directed at Black Americans [1][2][3][4][5]. Consequently, Black Americans' mental health suffers at significantly greater rates than White Americans [6][7][8]. Yet, despite greater harms to their mental health, people may paradoxically believe psychopathology harms Black Americans less than White Americans. People frequently believe that past hardships desensitize Black individuals to everyday social hurts [9,10]. The current work tested whether racial biases in social pain judgments extend to beliefs about the harms of psychopathology. We predicted that when presented with identical mental illnesses , participants would believe that psychopathology was less distressing to Black relative to White individuals. Moreover, we predicted that these distress biases would mediate effects on expected treatment --- Contribution of the current work The current work makes several contributions to research on pain, race, and mental health. First, these studies identify a racial bias in distress and treatment judgments relevant to the mental health crisis facing Black Americans. Over 400 years of racial violence and resultant social and economic inequality has produced sustained mental health disparities between Black and White Americans [22][23][24][25]. Yet, precisely when Black Americans mental health needs are pressing, many in society may paradoxically believe that Black individuals are hurt less and have weaker treatment needs than White individuals. The current work stands to provide evidence for a social-cognitive bias that undermines judgments of the mental health needs of Black Americans. Second, the minimization of Black individuals' psychological distress hints at a novel theoretical mechanism that may affect mental healthcare for Black clients. Heretofore, research on racial biases in mental health have focused on communication, trust, symptom interpretation, access to health services, and the role of prejudice in diagnosis and treatment [15,[26][27][28]. Racial biases in distress judgments complement this research and-because evaluations of distress are critical to every stage of mental healthcare [29]-provide evidence for a bias with wide-ranging treatment implications. Finally, the current work stands to advance research on pain biases beyond judgments of common social hurts to beliefs about the nature of psychopathology and mental healthcare. Rather than being limited to discrete and moderate social stressors , target race stands to bias judgments of chronic and extreme mental health conditions that shape the daily lives of countless Americans. Race-based biases in pain judgments extend to fundamental judgments of psychological distress and treatment needs. --- The current work Four studies tested whether people believe psychopathology harms Black individuals less than White individuals and whether biased distress judgments mediate racial biases in judgments of treatment needs. Study 1 paired images of Black and White individuals with ten mental illnesses and tested whether participants believed these illnesses would cause Black individuals less distress than White individuals. Study 1 also preliminarily tested whether MHPs showed similar racial biases in distress judgments. Study 2a-2b tested whether racial biases in distress mediated effects on treatment judgments. Study 3 tested whether racial biases in distress and treatment judgments extend to practicing MHPs. --- Study 1: Race-based bias in mental health distress judgments The current study's primary goal was to test our main hypothesis related to racial biases in psychological distress judgments. To test this hypothesis, ten Black and ten White male targets from the Chicago Face Database were paired with ten forms of psychopathology. The CFD is a frequently used and well validated stimulus set of adult target individuals from a variety of racial and ethnic backgrounds. Using norming data associated with face stimuli, we identified Black and White target individuals whose racial identity was easily identifiable while holding constant other facial features that might affect distress judgments . Thus, using normed CFD stimuli allowed us to manipulate target race without introducing confounds related to facial structure and morphology. Participants then judged the distress they believed each mental illness would cause these pictured individuals. We hypothesized that participants would expect psychopathology to harm Black individuals less than White individuals. The study's secondary goal was to explore whether potential biases in psychological distress generalize to those working in the field of mental health. With this goal in mind, we included a demographic item that allowed professional Mental Healthcare Professionals to self-identify. In light of evidence that implicit bias and stereotype endorsement is found among healthcare workers [17,28,31], there was good reason to predict racial biases in psychopathology judgments would extend to mental health professionals. --- Method Participants. Ethics approval was granted for this research by Miami University and Auburn University's Internal Review Boards, respectively. Written consent was presented via computer. Using the effect of target race documented in Deska, Kunstman et al. [10] d = .52, an a priori power analysis with G*Power software suggested a sample size of 32 participants would provide 80% power for the primary hypothesis test with a pairedsamples t-test. In anticipation of data loss and to provide a more robust test, we oversampled and collected data from 204 U.S. participants via the online research participation platform MTurk. MTurk is an internet-based participant service that allows researchers to connect with individuals interested in participating in social science research in exchange for payment to Amazon Marketplace. The identification of duplicate IP addresses resulted in 11 exclusions, leaving an analyzable sample of 196 . Including excluded participants does not change the direction or magnitude of any effects reported in Studies 1-2b. Differences related to analyzing complete data for Study 3 are discussed below. Full sample analyses for each study are located in the supplemental online materials. At no time did researchers have access to information that would reveal participants' identities. Sensitivity analyses indicated this sample provided power to detect minimum effects of d = .20. Data and materials for the complete work and pre-registration plans for Studies 2b and 3 can be located at . Materials. Participants viewed images of ten Black and ten White male targets from the Chicago Face Database . Black and White targets were equated on ratings of age, anger, attractiveness, baby-facedness, dominance, femininity, happiness, masculinity, racial prototypicality, sadness, surprise, threat, trustworthiness F range = 0.01-2.28, p range = 0.92-0.14. Specific tests of CFD norming data are available in the online materials and via the OSF link above. Target individuals were paired with a ten-item measure assessing harm caused by ten forms of psychopathology: depression, social anxiety, arachnophobia, post-traumatic stress disorder , bipolar disorder, panic disorder, insomnia, obsessive-compulsive disorder, generalized anxiety disorder, and schizophrenia. Participants rated how much psychological distress the pictured individual would experience if they had each form of psychopathology. Ratings were made on a 1 to 7 Likert scale. Distress judgments were then averaged within targets and combined across racial categories. Target images and psychopathology items were randomized. Participants' background in mental health was assessed with a single item embedded within demographic questions. Specifically, participants were asked whether they provide professional mental health services to others . Sixty-one participants responded yes to this item, indicating they had experience providing professional mental health services. Procedure. After consenting, participants completed the twenty-trial distress judgments task in an independently randomized order. After completing demographic information, participants were thanked, debriefed, and compensated for their time. --- Results A paired-samples t-test assessed the primary hypothesis that participants would believe psychopathology harms Black individuals less than White individuals. As hypothesized, when paired with the same forms of psychopathology, Black target individuals were judged to experience less distress than White target individuals (M = 4.64, SD = 1.26), t = -3.963, p < .001, 95% CI[-.19, -.064], d = 0.29. Since a meaningful subset of our 196 participants self-reported as MHPs , this allowed us to perform an exploratory test whether responses were moderated by professional background. To investigate this hypothesis, we conducted a mixed-model ANOVA where background was entered as a between-subjects factor and ratings of psychological distress for targets were entered as a within-subjects factor. Sensitivity analysis revealed this test had 80% power to detect small-to-medium effects . Results of this analysis reproduced the previously described main effect of target race, F = 7.85, p = .006, Z 2 p = .060 and produced a main effect of background, such that MHPs expected target individuals to experience more distress than members of the public . The interaction between participant background and target race was not significant, F = .36, p = .549, Z 2 p = .002. --- Discussion These results provide initial evidence that the public believes psychopathology harms Black individuals less than White individuals. Moreover, although clinicians expected target individuals to experience more distress than those in the lay public, racial bias in distress judgments were largely comparable between MHPs and the lay public . Although these results should be interpreted with caution given the relatively small sample of MHPs, there is some preliminary evidence that racial biases in psychological distress may extend to those working in mental health. In Studies 2a-2b, we next tested whether racially-biased distress judgments mediated effects on judgments of treatment needs. --- Study 2a-2b: Biased distress judgments inform treatment recommendations Study 2a had two primary goals. First, we aimed to further test the central hypothesis that people believe psychopathology hurts Black individuals less than White individuals. Second, we aimed to build on the bias documented in Study 1 to test whether racial biases in distress inform judgments of treatment needs. To test this treatment hypothesis, we added items assessing how many sessions of therapy pictured individuals would need to cope with mental illness. We hypothesized that biases in distress would bias treatment recommendations, such that participants would believe Black target individuals needed less treatment than White target individuals. Study 2b served as a direct replication of Study 2a's effects. --- Method Participants Study 2a. Using Study 1's effect estimate , a priori power analysis , suggested a sample of 33 participants would be needed to test the study's main hypothesis with a paired-samples t-test. We oversampled and collected data from an undergraduate student sample across a full academic term. This sampling strategy resulted in a sample of 198 participants. Of this sample, 29 participants failed at least one of the study's two attention checks, yielding an analyzable sample of 167 . Sensitivity analysis indicated that with 80% power this sample could detect effects as small as d = .22. Participants 2b. As a pre-registered replication of Study 2a, we sought a minimum analyzable sample of 190 participants. Expecting incomplete responses and exclusion, we oversampled 278 participants from MTurk. Of this initial sample, 68 participants failed at least one of the study's attention checks or produced a duplicate IP address , leaving an analyzable sample of 210 . Sensitivity analysis performed on this sample indicated that the current study had 80% power to reliably detect effects as small as d = . 19. Materials 2a and 2b. Participants completed the same distress task as participants in Study 1 with two noteworthy modifications. Participants were not asked about their experience providing professional mental healthcare. Participants also made treatment judgments for each mental health item. For example, following distress judgments of depression, participants were asked, "How many sessions of therapy do you believe this person would need to effectively cope with depression?" Participants made judgments on a 1 to 27 Likert scale. Judgments of pain and treatment were averaged across targets and racial categories. Procedure. Following consent, participants completed the twenty-trial distress and treatment task. Trial order and psychopathology items were randomized. Participants then completed demographic information, were debriefed, and compensated for their time. --- Results 2a Paired samples t-tests were performed to compare judgments of Black and White targets' psychological distress and treatment needs. Participants again judged Black targets to feel less psychological distress than White targets , t = -6.38, p < .001, 95% CI[-.24, -.12], d = .49. Participants also believed that compared to White targets , Black targets would need less treatment to manage their mental health, t = -8.26, p < .001, 95% CI[-.99, -.61], d = 0.64. Using the MEMORE macro to test within-subjects mediation [33], we tested whether race's effect on treatment judgments was mediated by judgments of psychological distress (Fig 1 --- Results 2b Paired-samples t-tested compared judgments of distress and treatment for Black and White --- Study 3: Tests among mental healthcare professionals Having provided consistent evidence of racial biases in judgments of psychological distress and treatment needs among the public, the current study tested whether these effects generalized-or were moderated-by experience in the field of mental healthcare. Consequently, we collected data from mental health professionals and members of the lay public. In light of preliminary evidence that MHPs showed smaller-but-comparable racial biases in psychological distress as laypeople , there was reason to suspect similar biases in treatment judgments, such that Black target individuals would be judged to need less treatment than White target individuals. To test these hypotheses, laypeople and MHPs completed the distress and treatment task from Studies 2a-b. --- Method Participants. We recruited 160 mental healthcare professionals and 258 members of the general public. The size of the mental health professional portion of our sample was the largest possible given the resource costs needed to compensate this highly-skilled and difficult-toreach population . MHPs were recruited through Qualtrics panel services by disseminating the survey to individuals who previously indicated that they provided mental healthcare as a counselor, clinical psychologist, psychiatrist, social worker, etc. At the start of the survey, participants indicated which field best represented their profession. To be eligible to continue participating, individuals needed to select the response option labeled 'Mental Health: counselors, clinicians, therapists, psychologists, psychiatrists, social workers, etc.' Individuals indicating other professions were funneled out of the survey. Lay participants were recruited through CloudResearch. Like MTurk, Cloudresearch is an online participant platform that allows interested individuals to participate in research in exchange for monetary compensation. Among lay participants, 176 identified as White, 4 as American Indian or Alaska Native, 12 as Asian, 46 as Black or African American, 14 as Latina/ o, 4 as Multi-racial, 1 participant identified as Hawaiian or Pacific Islander and 1 participant did not disclose their race . Among MHPs, 112 identified as White, 4 as American Indian or Alaska Native, 23 as Asian, 6 as Black or African American, 9 as Latina/o, 3 as Multi-Racial, 3 participants did not disclose their race . Here we would note that although detailed demographics for MHPs were cut to conform to the contracted study duration with Qualtrics, soft launch data from the first 30 MHPs indicated participants held advanced healthcare degrees with at least five years of clinical practice . Of the total sample of 418, 139 participants were excluded for failing the study's attention check or for presenting a duplicate IP address that could indicate botresponding . After exclusions, the study achieved an analyzable sample of 262 . Sensitivity analysis suggests this sample provided 80% power to detect an interaction between participants' background and target race as small as d = . 34. Materials. Using the task from Studies 2a-b, participants made judgments of psychological distress and treatment needs. However, to account for greater nuance in treatment recommendations, the treatment scale was expanded. Units 1-26 were on an interval scale 1 , 2 . . .26; options 27 and 28 encompassed greater amounts of therapy sessions. Procedure. Following consent, participants completed the distress and treatment task for Black and White targets. After completing demographic items, participants were debriefed, thanked, and compensated for their time. --- Results We conducted a mixed-model ANOVA where participant background was entered as a between-subjects factor and distress judgments corresponding to target race were entered as a within-subjects factor. Results of this analysis yielded a significant main effect of target race, F = 12.39, p = .001, Z 2 p = .045, such that Black targets were judged to experience less psychological distress than White targets . Neither the main effect of background, F = 1.22, p = .270, nor the interaction between background and target race, F = 1.95, p = .16 reached significance. Turning to treatment judgments, we again conducted a mixed-model ANOVA with participant background as a between-subjects factor and target race as a within-subjects factor. Results of this analysis produced a significant main effect of target race, F = 10.90, p = .001, Z 2 p = .040 and a significant interaction between target race and participant background, F = 6.50, p = .011, Z 2 p = .024. The main effect of participant background fell short of significance, F = 3.29, p = .071, Z 2 p = .013. To decompose this interaction, we first conducted paired samples t-tests for treatment judgments for Black and White targets separated by participant background. Lay participants again judged Black targets to need less treatment than White targets , t = -4.09, p < .001, 95% CI[-.77, -.27], d = 0.33. However, MHPs did not differ in their treatment judgments between Black and White targets, t = -.58, p = .56, 95% CI[-. 29, .16], d = 0.06. Additional independent samples t-tests analyzed the effect of background on treatment for Black and White targets separately. These tests found that although members of the public judged Black targets to require significantly less treatment than MHPs , judgments for White targets did not significantly differ between lay participants and MHPs t = -1.63, p = .11, 95% CI [-3.15, .30], d = 0.20. As outlined in our pre-registration, using the MEMORE macro , we tested whether target race had an indirect effect on treatment judgments via racial biases in psychological distress. Mediation analyses were conducted separately for lay participants and MHPs. Among lay participants, race's effect on treatment outcomes was mediated by biased judgments of psychological distress, b = -.37 SE = .09, 95% CI [-.54, -.13]. However, analysis among MHPs revealed that target race's indirect effect on treatment recommendations via distress judgments did not reach significance, b = -.14 SE = .07, 95% CI [-.28, .01]. Suspecting that power prevented the pre-registered mediation analysis from achieving significance, we performed an exploratory mediation analysis on the full sample of MHPs . Before conducting this analysis, we first tested whether responses differed between MHPs that passed v. failed the attention check and whether attention check responses interacted with judgments of distress and treatment. Results of these analyses revealed that MHPs provided similar responses whether they passed or failed the attention check, Fs< 1.00, ps>.36 and attention checks did not interact with effects of target race, Fs <1.00, ps>.75. Bolstered by these results, we tested whether distress judgments mediated race's effect on treatment judgments for the full sample of MHPs . Results of this analysis provided evidence that among MHPs, racial biases in distress mediated target race's effects on treatment judgments, b = -.17 SE = .07, 95% CI [-.32, -.04]. --- Discussion These results provide further evidence that the public believes psychopathology harms Black individuals less than White individuals and, consequently, believe Black individuals have weaker treatment needs than White individuals. Critically, the current study provides suggestive evidence that these biases extend to practicing MHPs. Like members of the lay public, MHPs judged Black targets to experience less psychopathology-related distress than White targets and-when analyzing data from all available MHPs-these biased judgments mediated target race's effect on treatment judgments. Although the direct effect of target race was not significant, exploratory analysis of all sampled MHPs revealed that race operated through racially-biased distress judgments to inform treatment recommendations. This exploratory analysis provides evidence that racial biases in judged distress generalize to MHPs and indirectly affect treatment judgments. --- General discussion Recognizing distress is critical to mental healthcare. The mental health needs of Black Americans are particularly pertinent when considering the tolls of the COVID-19 pandemic and ongoing violence and harassment directed at Black Americans [3,5]. Yet, at a time when Black Americans face multiple mental health crises, it appears that many in society-including some working in mental healthcare-paradoxically believe psychopathology hurts Black individuals less than White individuals. Evidence from four studies provide consistent evidence for this racial bias in mental health judgments. Lay participants and MHPs similarly believed that mental illness was less distressing to Black individuals than White individuals. Moreover, among lay participants, biased distress judgments mediated similar racial biases in care recommendations for Black relative to White individuals. Among MHPs, racially-biased distress judgments indirectly informed judgments of treatment needs. Although care should be taken when interpreting effects among MHPs, exploratory analysis of the complete sample suggests that racial biases in distress extend to practicing clinicians and indirectly influence treatment judgments for Black and White individuals. --- Implications The current results make several key contributions. First, racially-biased judgments of psychological distress bear directly on the mental health crisis facing Black Americans. At a time when suicide rates and mental health needs are rising among Black Americans [34], portions of the public and MHPs paradoxically believe that psychopathology hurts Black individuals less than White individuals. Racial bias in distress judgments is directly relevant to the mental health challenges faced by Black Americans. Second, racial biases in distress judgments represent a novel theoretical mechanism for understanding racial disparities in mental healthcare. Because judgments of distress are essential to every step of the treatment [29], racial disparities in psychological distress judgments stand to have numerous negative effects across the treatment process . Racial biases in distress judgments may contaminate numerous stages of mental healthcare. Third, the minimization of Black individuals' psychological distress and treatment needs advances research on pain biases to chronic and extreme mental health conditions. These findings illustrate that race's effect on judgments of social hurts are not relegated to common everyday slights, but extend to judgments of highly distressing experiences and crucial mental health needs. By documenting race's effect on mental health judgments, these results advance research on biases in pain judgments generally and research on social pain biases specifically. Fourth, racially-biased mental health judgments may affect multiple life contexts. At work and in school, authorities often have wide latitude for providing time off, excused absences, and deadline extensions. Widely held beliefs that minimize the psychological distress and mental health needs for Black individuals stand to undermine accommodations and support in numerous interpersonal contexts. Finally, racial biases in mental health and treatment needs have negative implications for interventions and programming to ameliorate racial disparities in mental health. Perceived need fuels funding priorities in both the public and private sector [35]. Consequently, racial biases that undermine conceptions of the psychological distress and mental health needs of Black Americans may negatively affect government and philanthropic resources directed toward Black mental health. --- Limitations and future directions Limitations offer avenues for future research. Although the current research offers compelling initial evidence for a race-based bias in psychological distress and consequent treatment judgments, caution should be exercised when extrapolating these experimental results to the population writ large and the diverse field of mental healthcare professionals. Among laypeople, although the consistent replication of distress and treatment judgments provides evidence of the generality of this bias, replication among a nationally representative sample of American adults would provide even greater support for the durability of these effects. Among clinicians, more detailed replication, particularly with larger and more diverse samples with ecologically richer stimuli would provide greater understanding of the effect of client race on MHPs' judgments of distress and treatment. First, larger samples affording greater statistical power will provide greater evidence of the reproducibility of Study 3's effects among MHPs. Second, future research should test the role of clinician race and training orientation to potentially moderate distress and treatment judgments. Although there is some evidence from research on physical and social pain judgments that Black and White individuals often show similar biases [10,14], presumably because of the nominally positive nature of stereotypes related to Black strength and resilience, it is not clear whether these effects generalize to Black clinicians and those trained in more culturally competent approaches to mental health [36][37][38]. Future research should test for moderators among MHPs. Third, researchers might test how client race shapes distress judgments in more ecologically valid contexts. For example, guided by methods for testing social accuracy in emotion perception [39,40], stimuli could be created in which actual Black and White clients report their distress before and during structured clinical interviews. Segments of these interviews could then be presented to novel clinician participants tasked with judging clients' distress at focal interview moments. To the extent that Black and White clients have moments of low and high distress and these experiences can be matched across target client race , this procedure would allow researchers to manipulate target race while holding client distress and personal characteristics constant . Additionally, such a procedure would allow researchers to not only test whether MHPs minimize Black clients' distress relative to White clients' distress, it would also afford tests of whether they underestimate Black clients' distress relative to the clients' actual emotions. Although resource and labor intensive, replicating Study 3's effects using such ecologically rich stimuli would provide even stronger evidence that race biases clinicians' judgments of Black clients' distress. In sum, although the current results offer initial evidence that laypeople and MHPs minimize the distress of psychopathology for Black relative to White individuals, care should be taken when extrapolating these findings to the broad field of mental health. Future research would provide greater support for these findings by testing effects with bigger and more diverse samples and with even richer experimental stimuli. Just as pressing, future research must also investigate mechanisms to eliminate racial biases in mental health and treatment needs. Considering evidence that mindfulness and perspective-taking sometimes spotlight the harms of discrimination and racial inequity [42,43], strategies geared at improving perspective-taking and mindfulness may mitigate biased distress and treatment judgments. Another limitation of the current work is its exclusive use of male target individuals. Although there is evidence that racial biases in social pain judgments occur for Black female and Black male target individuals [10] and clinicians under-diagnose certain forms of psychopathology for Black female relative to White female clients [44], other social cognitive work highlights that race is sometimes gendered, producing unique biases toward Black female targets [45]. Future research should test whether target race and gender produce independent or interactive effects on judgments of psychological distress and treatment recommendations. Future research should also test whether racially-biased distress judgments affect the therapy strategies MHPs provide Black clients. There is evidence that clinicians are less likely to use cognitive change strategies with Black versus White clients [46]. To the extent that cognitive change strategies are critical to care, providing less of this "ingredient" may dilute therapy's effectiveness for Black clients. Future research should examine whether clinicians' racial biases in distress judgments shape therapy decisions, retention, and care outcomes. Finally, future research might also explore how biases in psychological distress are shaped by other group identities. For example, other social groups are judged as tough and insensitive to pain , have their emotional capacities dehumanized , and feel their social hurts are invalidated . Future research should test whether biases in mental health and treatment needs extend to individuals from diverse social backgrounds. --- Conclusions At a time when Black Americans' mental health needs are pressing, the current work provides consistent evidence for a racial bias in mental health and treatment judgments. Members of the public and practicing mental healthcare providers believed psychopathology harms Black individuals less than White individuals and these distress biases informed treatment judgments. These biases represent a social-cognitive obstacle to achieving mental healthcare equity and require urgent address to meet the critical needs of Black Americans. --- All data files are available on the Open Science Framework. https:// osf.io/kj6yz/?view_only= a201a27d263e42a4af60d4f563601cb8. --- Supporting information --- S1 File. ---

Racism creates and sustains mental health disparities between Black and White Americans and the COVID-19 pandemic and ongoing harassment directed at Black Americans has exacerbated these inequities. Yet, as the mental health needs of Black Americans rise, there is reason to believe the public paradoxically believes that psychopathology hurts Black individuals less than White individuals and these biased distress judgments affect beliefs about treatment needs. Four studies (two pre-registered) with participants from the American public and the field of mental health support this hypothesis. When presented with identical mental illnesses (e.g., depression, anxiety, schizophrenia), both laypeople and clinicians believed that psychopathology would be less distressing to Black relative to White individuals. These distress biases mediate downstream treatment judgments. Across numerous contexts, racially-biased judgments of psychological distress may negatively affect mental healthcare and social support for Black Americans.

T he relocation of older people to housing designed for that age group is usually different from other transitions earlier in life, as it is based on reasons such as failing health, the need for assistance, or loneliness. 1,2 Research has indicated both positive and negative aspects of such relocation. 3,4 Despite the emphasis on the importance of physical activity in old age, [3][4][5][6][7][8] the literature is sparse on how living in housing for older people affects their PA behavior. Yet, research into PA and the physical and social environment, as well as caregiving responsibilities, indicates the need for such studies, especially among older women. Many studies indicate the importance of the physical environment for PA. 9 -11 In particular, density, walkways, accessibility of stores, traffic safety, and no fear of crime or unleashed dogs are factors in the physical environment that positively affect the PA of the residents of retirement communities. 9,12,13 On the other hand, a systematic review of potential environmental determinants of PA indicated that only 2 factors were associated with vigorous PA: the availability of PA equipment and a network of trails. 14 Studies on the relationship between weather and PA are rare, and few consider a colder climate or a continental climate. A qualitative study of the northern physical environment and the well-being of older people revealed that cold, snow, light variation, and distances influenced the well-being and PA of older people. 15 As walking seems to be the most common form of exercise of older people, 16,17 colder climate could be a barrier to PA, but research is lacking in this area. Studies on the influence of the social environment on PA have identified that social support and having a companion for PA have a strong associa-tion with PA. 14,18 Research results also have indicated an association between self-efficacy and PA, 13,19,20 and fear of falling is probably the most important factor in predicting activity avoidance among older adults. 21 In addition, there are possible links between intrinsic motivation and greater PA, as well as some kind of extrinsic motivation facilitating PA . 22,23 In late adulthood, decreasing family and job responsibility may lead to older people experiencing more free time and having more opportunities to participate in organized PA. A former positive experience of PA also may be a strong facilitator for older people to become active again. 24 However, caregiving responsibilities because of a frail spouse can be a barrier to PA, whereas leisuretime PA is possibly dependent upon how active the spouse is, especially for women. 25 Sex differences may exist in this area in that family responsibility and caregiving responsibilities could affect women's participation in PA more than men's participation. 26,27 A retirement community is a housing option commonly used by older adults. It is usually a multiresidence housing facility, and additional facilities often are provided within the building for meals, gatherings, recreation, and some form of health care. Women comprise the majority of the residents of these communities due to living longer. They may be more dependent than men on the neighborhood of the retirement community because they are less likely to drive a car, 28 and research indicates that women living in urban areas are less physically active than men. 13 Therefore, the purpose of this research was to study in depth the PA experience of older women and to understand their lived experience of facilitators and barriers to PA in retirement communities. --- Method Study Design The study was qualitative and guided by the Vancouver School of doing phenomenology. 29 The Vancouver School is an interpretation of phenomenological philosophy and is a unique blend of phenomenology, hermeneutics, and constructivism. Placed in a philosophical context, the Vancouver School: . . . espouses a world that is made up of meanings which profoundly affect how people experience and live their lives. . . . The Vancouver School stands for moderate realist ontology . . . a transactional epistemology, and a hermeneutic dialectical methodology. The inquiry aims are oriented to the production of reconstructed understandings . . . and a commitment to the study of the world from the point of view of the interacting individual. 29 The number of participants in typical studies that utilize the Vancouver School approach is usually 5 to 15, or at least 10 dialogues . The constructivistic approach of the Vancouver School means that the researchers using this methodology usually present their findings as a construction and typically as a model or a table. The Vancouver School emphasizes that researchers, as "specialists," aim to put away preconceived ideas and to stay open to hearing something new when they participate in the interview. This aim can be complicated because all of our attempts to understand and interpret the world are affected, usually to a large extent, by the tradition and society we live in. 30 --- Recruitment of Participants We recruited participants based on the following inclusion criteria: be a woman, be at least 70 years old, have lived in a retirement community for at least 6 months, and --- Facilitators of and Barriers to Physical Activity in Retirement Communities be able to communicate verbally and share her experience. We used various ways to recruit participants to avoid the sample being elite. We sent posters to all women in a few retirement communities, and some women were approached directly. Moreover, we used a network of colleagues, janitors, and caretakers within retirement communities to distribute information about our study. Of those women who were willing to participate, we recruited participants purposefully, aiming for both physically active and inactive participants who were single, married, or widowed. The participants were 10 women, 72 to 97 years old . They had lived in retirement communities from 6 months to 20 years , and all were able to walk independently indoors and outdoors, with or without a walking device. Further information about the participants is presented in Table 1. --- The Retirement Communities The women lived in 7 different retirement apartment buildings, all in the same urban area. The ownership of the apartments differed, as 2 were privately owned, 3 were rented from private companies, and 5 were rented from the municipality. All of the retirement communities shared a floor plan that allowed the women to walk indoors into a service center with a dining hall and recreation facilities. Only the apartments rented from private companies had access to a physical therapy facility indoors, but all participants had the right to receive home care physical therapy. --- Data Collection and Analysis The study was approved by the National Bioethics Committee and reported to the Data Protection Authority . All participants were given written information about the study and signed an informed con-sent statement before entering the interview. The first author conducted all interviews in 2009. They took place at each woman's home or in a service center within the retirement community, depending on her preference. Two of the 10 women were interviewed twice to gain a more in-depth understanding of their experience . Interview questions were open, based on the main interview question: What is your experience regarding PA in this retirement community, and what are the main facilitators of and barriers to your PA? The data collection and data analysis were based on the 12 basic steps of the research process of the Vancouver School . Interviews were recorded and transcribed, and transcriptions were analyzed for main themes and subthemes. These findings from each interview were constructed into an analytic framework . The first author repeated this procedure for each woman until a holistic understanding of her PA experience seemed to be captured. Each of the 10 analytical frameworks was verified with each woman to make sure the researcher understood her words correctly . This process was done by showing each woman the framework that the researcher had constructed based upon the interview. Following the first 3 interviews, all 3 authors started the construction of the main analytical framework . Thereafter, data collection and data analysis ran concurrently as each interview was analyzed and verified by the participant, and the resulting framework was used to add to the main analytical framework. When all 3 researchers concluded that nothing new had been heard in the 2 last interviews, saturation was --- Validity and Reliability The research process of the Vancouver School has some built-in strategies designed to increase validity and reliability, particularly member checking in steps 7 and 11 . The researcher triangulation in this study proved fruitful, especially in steps 8, 10, and 12, where the expertise of 3 professionals were combined. Triangulation is one of the strategies designed to increase validity and reliability in qualitative research. 29 Peer debriefings and thick description also were used as strategies to increase validity. Because of the effects of constructivism within the Vancouver School, reflexivity is a given. The findings are a construction of the researchers, built on the data. A reflective diary was used at all stages of the research process, as required in the Vancouver School. 29 Finally, we asked an external auditor, who was unfamiliar with the project, to critique a detailed research report at the conclusion of the study and to review the entire research project. The auditor's contribution, we believe, enhanced the overall validity of the study. --- Role of the Funding Source This study was supported by grants from: The Housing Financing Fund in Iceland, The Research Fund of the Icelandic Physical Therapy Association, The Research Fund of Hrafnista, and The Research Fund of the Geriatric Council in Iceland. The funding sources for this study had no role in the study's design, conduct, or reporting. --- Results The women had lived in retirement communities for up to 20 years. While they were recounting their current PA experiences, they also vividly recalled their initial encounters and the factors that influenced their adjustment to the retirement community. Figure 1 is a schematic representation on how the women described their PA development --- Steps in the Research Process What Was Done in the Present Study Step 1. Selecting dialogue partners Each woman was selected through purposive sampling. Step 2. Silence Preconceived ideas were deliberately put aside. Step 3. Participating in a dialogue One or 2 interviews were conducted with each woman. The first author conducted all of the interviews. Step 4. Sharpened awareness of words After transcriptions were made, they were read over and over again. Step 5. Beginning consideration of essences The researchers tried repeatedly to answer the question: What is the essence of what this woman is saying? Step 6. Constructing the essential structure of the phenomenon from each case The main factors in each woman's story were highlighted, and the most important factors were constructed into an individual analytic framework. Step 7. Verifying each case construction with the relevant participant Each woman verified the analytic framework pertaining to herself. Step 8. Constructing the essential structure of the phenomenon from first 3 cases into a main analytical framework . Thereafter, analytical frameworks from the subsequent participants were merged one-by-one into the main analytical framework and consequently added to the themes. All 3 researchers participated in this process and made sure the main analytical framework constructed was based on the actual data. When no new themes were found, saturation was considered to be reached. Step 9. Comparing the essential structure of the phenomenon with the data All of the transcripts were read over again and compared with the meta-synthesis of all the different case constructions. Step 10. Identifying the overriding theme that describes the phenomenon The main theme was "Facilitators of and Barriers to Physical Activity in Retirement Communities: Experiences of Older Women in Urban Areas." Step 11. Verifying the essential structure with some research participants The results and the conclusions were presented to and verified by 2 of the participants. Step 12. Writing up the findings The participants were quoted directly to increase the trustworthiness of the findings and conclusions. A schematic representation of the women's physical activity development after moving to a retirement community, including critical initial and present facilitating and hindering factors. --- Facilitators of and Barriers to Physical Activity in Retirement Communities --- Participant --- Facilitators of and Barriers to Physical Activity in Retirement Communities after their relocation. All of them described facilitating and hindering factors to PA within their retirement communities. The current PA experiences of the women varied, yet 3 main themes were constructed based on the origins of the facilitating and hindering influences . These main themes were the physical environment, the woman herself, and the social environment. --- Facilitators Physical environment. Nearly all of the women found it important to take a walk outside. In relation to this, the importance of nonslippery sidewalks was clear. If there is ice, "we walk around here on the [nonslippery] sidewalks. . . . I find it necessary to have [such nonslippery] sidewalks . . . this is something you don't notice until you have to use it." Outdoor areas also played an important role in the women's lives, for example, having a balcony, shelter from the wind, benches along walking paths, and walking areas with no hills: We can always sit down when we walk along X street . . . on the stones there, so it is not so difficult. That area is nearly all flat and even, with no hills or anything, which I have a bit of difficulty walking on. Each of the women had her own method of getting to the grocery store. Many were assisted by their children because the stores were too far away. Those women who had had stores close by in the past mentioned how physically stimulating it had been going shopping: "I just found it very nice moving here [retirement community]. There was a store close by, and I just went there and did not need any help. . . . That meant I could go to the store sometimes more than once a day." Finally, the women all enjoyed going out and getting fresh air. Indoor features came in handy when the weather was too poor to go out: "I run down the stairs here at least 4 to 5 times a day." Thus, it was evident that access to exercise facilities within the residence was an important factor in encouraging PA, especially when the weather was too poor to go out: "I think it is very good to have this kind of facilityvery good." --- Figure 2. Older womenЈs experience of facilitators of and barriers to physical activity in retirement communities. --- Facilitators of and Barriers to Physical Activity in Retirement Communities The woman herself. The findings indicate that former lifestyle made a difference: "[I have] always been very good about being active. . . . Yes, if I remember correctly, I've always walked quite a bit." Many women thought they were healthy compared with their neighbors. However, the women had different interests in PA and varied as to whether their motivation was enjoyment or the results that activity gave: "I find it fun, but it is also to get fresh air, oxygen. . . . I really enjoy that. I feel so much better afterwards." Having self-efficacy was a facilitator for the women: "I am also not afraid of just going out and doing. . . . I can be outside for up to an hour. I can do that without a problem." They used PA to cope with pain, which is something that they had learned in physical therapy: ". . . in my arm mostly, [I] had arthritis. . . . So I went to the physical therapist. It had a good effect on me. . . . I feel that I improve when I receive it [physical therapy], and worsen again when I don't." Their experience of their own health also had an impact, and a few women spoke of how lucky they were to be in good health: "I am so lucky to be fairly hardy. . . . I have been so wonderfully healthy." Those women who were socially active seemed to have an easier time being physically active, and the company of others had an encouraging effect on them: "There is quite a lot of social life here . . . and I try to go as much as I can. . . . It doesn't help [to isolate yourself]; then you are simply done for." In some cases, the women had organized walks in the neighborhood: "We have organized ourselves, and we always go when the weather is nice." Those women who lived organized lives were more diligent in being active, and they had movement scheduled into their daily routines: "I have a bit of a program, which is fairly comfort-able. . . . I usually go out early in the morning for 15 minutes." Social environment. Motivation from family members was important, and most of the women who were physically active had families who encouraged them: "[My daughter does] not worry about me; she encourages me to go out and be independent." Not having caregiver's responsibilities also facilitated the women's PA: "When you are alone, you have more time." Training offers had to match their capabilities and interests: "Her exercises [the physical educator's] are very good." A few women who were active described some sort of a PA culture in their retirement communities: "In the summer, we just go and exercise with a special exercise program on the radio. Though I've done it for years at home, it's very clever to meet up in the dining area." Some residents met to go for walks together: "There are a few of us who go together sometimes." Two women in the group had had home care physical therapy, which they liked very much and which they felt encouraged them to be more active: "I often go out here in the hallways to walk, and I go over the exercises that my physical therapist has me do." Barriers Physical environment. The weather condition that had the most effect on the women was ice: "You are naturally afraid of [walking on] ice, afraid of falling. . . . You take more care, don't walk as energetically." Wind also was a barrier: "It is really dangerous to go out when it's windy; you could be swept away. . . . There has been such bitter weather, and so you can't really be outside because of the cold." Hills and stairs were great hindrances for the women who lived in such areas: "I am so tired of the hills here just near the building. It takes a lot of effort to walk when you have a walker." As most of the women wanted to be able to go out for a walk, the landscaping of the surrounding areas was a major concern. Benches to rest on were much needed: "It saddens me . . . there are too few seats or benches, there are hardly any, except in a very few places." Darkness was also a barrier to PA, and a fear of going out in the dark due to the rising crime rate was noted: "You are just always hearing about it [news of crime]." Those women who did not have a store nearby complained that they needed help with that aspect of their housekeeping, which was difficult for some: "It's just difficult, you see. If I get my children [to] shop with me . . . it is even more difficult." Two women spoke specifically about how good it would have been to be able "to age in place," not having to relocate to the retirement community. They named some barriers to being active in their present environment and expressed a longing for the old neighborhood they knew and had lived in all their lives: "It was just very nice there [in the old neighborhood]; we went out every day and walked a lot, but here I go out very little." The woman herself. The inactive women in the study had, for the most part, never taken part in any physical training: "I have just never done it, have never been in any kind of physical exercise. . . . I was a competent swimmer, but I didn't go after I'd had my children." The women's amount of interest in activity also varied. The inactive women in the group felt they had to be physically active either to avoid negative consequences or to improve their health, but nevertheless they often simply had no motivation overall: "I don't move around very much . . . [inactivity is] like a spider web that you can't get out of if you've gotten stuck in it." Low self-efficacy and fear of falling were --- Facilitators of and Barriers to Physical Activity in Retirement Communities limiting for many women and suppressed their PA: "I fell, and I haven't gotten around since then. . . . I have less courage." Two of the women had experienced difficult hospitalization after a fall, which made them horrified even thinking of experiencing that again. "I had a horrible experience in the hospital. They gave me the wrong drugs . . . and instead of talking to me, they made fun of me . . . almost 2 years passed until I could talk about it without crying [sobs]." Lack of sociability was a potential hindrance to PA, especially after losing a spouse: "It takes time to get going . . . also because I didn't have a driver's license. It was as if I'd been locked in a closet, you are completely cooped up." The women's health also made a big difference, and some felt clearly how failing health impeded their ability to be active: "I can't move very much due to pain in my back. . . . I can only walk a bit." One of the women experienced "a complex because of the stoma," and that stopped her from going swimming. A difficulty with dressing was a hindrance for the 2 women in the worst health, which can be a factor in inactivity: "I find it a bit hard to dress myself. I dress as seldom as possible. Yes, you have to bend and such. You have to dress yourself twice a day." Social environment. There were various ways in which family could work as hindrances to the women. In some instances, the family was rather distant and was perceived by the woman as indifferent: "They [the family] leave me for the most part alone now. They always have so much to do." Two women lived with their frail husbands, which affected how often they were able to go out for walks: A few women mentioned that the physical training offered at the service centers in their retirement community was either too difficult or did not meet their needs: "They [physical educators] come here, but I can't handle it because of my back. . . . I have gone to the pool, but I don't think that it is good for me." None of the women experienced encouragement to be active from the employees of the service centers: "We get no encouragement." Those women who moved little and were socially isolated also experienced little in the way of a PA culture: "It is not common [that people are out walking]. . . . She was saying that she never sees a single person out here walking in the mornings." --- Discussion The findings of this study provide a valuable insight into older women's experiences of PA in retirement communities. The women described a variety of influencing factors, which either facilitated or hindered them in being physically active. The model we constructed from the women's experiences delineates the facilitators of and barriers to PA among the women studied who were living in these retirement communities. These facilitators and barriers are categorized under 3 main themes and reflect the characteristics of the women themselves as well as their physical and social environment. --- The Woman Herself The woman herself is a theme that includes subthemes associated with the woman's health condition, individual aspects of functioning, and various personal factors. These subthemes focus on lifestyle, social background, and psychological characteristics that can both facilitate and hinder PA. Personal factors such as motivation, self-efficacy, and fear of falling are all factors that former studies have shown be related to PA. 20 -23 The necessity of having fun doing exercise or staying physically active was very important to the women, which should be recognized by physical therapists when training older people. It seems that fun is of importance regardless of age. 31 Good self-esteem and selfefficacy also were important facilitators of PA, a finding that supports the findings of other studies. Physical activity has been found to be related not only to better physical health but also to better self-esteem, less fear of falling, and more experienced mastery or self-worth. 13,19,32 In this study, the impact of falling was a strong factor, and, unfortunately, a stay in the hospital made things worse. It is certainly very important to consider whether a fear of falling, after a prior fall, is exaggerated by uncaring personnel. Supporting results from other studies, 23 the women in our research expressed concerns about their health. However, the women varied in how they experienced their health. Many women thought they were healthy compared with their neighbors, which corresponds to the results of other studies. 33 Health challenges, such as a stoma, appeared as a major barrier, and support and education on living with a stoma were lacking. The 2 women with the worst health --- Facilitators of and Barriers to Physical Activity in Retirement Communities problems mentioned difficulties in dressing and undressing as a barrier to PA, which also was reported in a study on people with osteoarthritis. 34 Some of the women living a structured daily life had put PA in their daily program, thus helping themselves to stay physically active. This finding is similar to results from a qualitative study on long-term exercise adherence in women, 31 which indicated that using self-regulation strategies and goal setting increases women's PA. Perhaps those who live structured lives are more likely to exercise than those who do not. Physical therapists should bear this factor in mind when encouraging older women to be physically active and even assist them in making a PA schedule if they have not made one by themselves. Moreover, such a schedule could be a part of a specific activity plan, which is strongly recommended for obtaining sufficient PA among older adults. 7 The women in our study who were currently active had all had an active lifestyle in the past. The literature is not consistent on this point; some studies have indicated that former lifestyle is a facilitator, and others suggest that it does not matter. 24 Research results have indicated that PA at the ages of 30 to 50 years is associated with walking as a form of exercise in old age. 17 Therefore, former lifestyle may affect PA in old age and is part of the person's life story. --- Physical Environment The design of housing and environment was important for the women, and all of the women described icy sidewalks as a barrier to PA. Nonslippery walkways should be part of housing design for the older individuals in northern climates. Wind also was a barrier for the women, and sheltered walkways were lacking. Hills were a barrier for some women, which indicates that if there are hills in the neighborhood, special features such as benches are needed. 35,36 Benches for resting were facilitators for PA, a finding that is in line with other studies of the walking habits of older people. 37,38 Darkness was a barrier for 2 of the women, something to remember when organizing exercise for older people. Exercise should be performed during the day and in daylight, unless they can go to exercise classes indoors. 15,23 The effect of seasons and weather on PA varies in different parts of the world. Weather can be a barrier to participation in PA, and poor or extreme weather in various areas may hinder such behavior. 39 That is why providing indoor exercise facilities for PA is necessary when the weather does not allow outdoor activity. All of the women wanted to be able to go shopping, and a local shop has been shown to be important to facilitate walking for older women. 12 --- Social Environment In the study, it appeared that being familiar with the surroundings was a facilitator of PA, as well as living in a familiar neighborhood. We found no study on this matter, yet, according to our findings, place of origin matters to older people. Hence, retirement communities should be a part of every greater neighborhood or subdivision, with good connection with the surroundings. As all participants mentioned walking outdoors as a priority exercise, the physical environment is an important factor. If older people move into an unfamiliar area, they might need support from their family or staff to get to know these new surroundings. Sociability appeared as a facilitator of PA, and research results indicate that women seem to be more dependent than men on a social network and that it is possible a lack of sociability could be a barrier to women min-gling with other people in PA. 14,17,40 Physical therapists who organize physical activities for older women also should note that most of the women complained that exercise classes in the service center were too difficult. The decision to move to retirement communities has been found to be partly in order to minimize caregiving responsibilities and to gain independence. 2 This finding is supported by the results of our study. However, an encouraging family was important for the women in our study, and having a meaningful relationship with their children seemed to help them cope with worsening health, as reported in other studies. 17,[41][42][43] Being a caregiver for a spouse influenced how much the women could take care of their own health, including PA. Two of the women experienced being confined by frail spouses, which is in line with another study indicating that the PA of the partner was the most significant predictor of PA of the participants. 25 Such a life situation raises thoughts about how taking care of a frail partner may be a physical burden in itself and, as a consequence, be detrimental to regular exercise and meeting friends. Whether this factor is more prominent for women than men is not evident. In the literature, however, there are some indications that older women rather than men experience more negative interactions involving close relatives or a frail partner, a situation that also appears to create stronger psychological distress in the women. 43,44 Therefore, women taking care of frail partners may need empowerment and special support from physical therapists. Additionally, among older women, the culture and sex roles do not necessarily expect them to prioritize their own health, 31 a point that should be noted by physical therapists. --- Facilitators of and Barriers to Physical Activity in Retirement Communities Family history affected the women's current health and well-being. They reported that relationships with their children were very important, and perhaps these family ties become more crucial as people become older and frailer. 43 Moreover, a history of residence and knowing the neighborhood were important indicators of a successful transition to a retirement community. This fact should receive more attention in research on aging. The women did not experience any encouragement from staff to be physically active. The only professionals encouraging the women were the home care physical therapists. As encouragement from important others is considered to be an influencing factor regarding PA, 23 this is something that might be changed by informing the staff how important their encouragement is. The women experienced a PA culture in different ways, probably in line with how active they were themselves. Older people are facing a new reality when they move into retirement communities or any kind of housing for older people. Their role models for this change are vague; few had parents living in such housing. In that sense, older generations today are creating new norms, and professionals can help to create a positive PA culture for the promotion of health. Changes that happen too fast or are being forced into a new culture without the understanding or time to adapt can threaten the self-efficacy of older people. A cultural lag can easily occur when the attitudes of older people do not keep up with the development of housing for them. This fact is something to bear in mind when a PA culture is introduced into a retirement community. In interpreting the results of our study, it must be kept in mind that the participants were all born in the first half of the 20th century and were middle-aged or older when sport and exercise among the general public became popular. Despite this change in cultural outlook, many women had adopted the newer lifestyle, an indication of the adaptability of older women. On the other hand, when organizing PA for older women, especially the very old, it must be realized that their norms can be very different from those of younger people. Moreover, with the baby-boomer generation becoming seniors, physical therapists need to be prepared for continuing changes in the norms and culture of older people. --- Interactions Between Themes According to our findings, when family, staff, housing design, surroundings, exercise offers, and other services in the retirement community are coordinated and based on the needs of the older women, the result should be for the good of the women. The coordination between the family and staff is obvious, but researchers in this area have pointed out the necessity of good communication between staff and family to ensure a better quality of life for the residents. 45 If a woman has no family or children, the importance of staff is even greater. The idea of transition to a retirement community is quite often originated by the children. 1 People need to study the neighborhood and be diligent when choosing retirement communities for themselves or their parents. Designers need to be aware of the influence of services in the neighborhood, such as shops, and managers need to offer exercise classes that fit the residents' needs. --- Limitations While choosing participants in the study, a sampling bias might have occurred because it was impossible to make sure that the sample was perfectly representative of the population. The most likely possibility was an elite bias, which occurs when women who are more active and talkative are more prominent in the sample. Another bias might be that, as researchers, our interpretation of the findings was shaped by our own background, such as our sex , culture, history, and socioeconomic origin. Although we are equally Icelandic, we are not of the same generation as our participants. As in all qualitative studies, our preconceived ideas could have influenced the results. The interviews were conducted in one geographic area, which might be a limitation because weather, experience, and culture could have been so similar as to prevent the expression of the diversity of people. The women had lived in a retirement community for up to 20 years, which certainly can make it difficult to remember and express changes. Finally, as all of our participants were women, future research is needed on the PA experiences of older men living in retirement communities. --- Conclusions An older woman's residence is an environmental factor that may strongly influence her ability and motivation to be physically active and thereby act as a preventive measure against disease and functional decline. This study gives information on facilitators of and barriers to PA among older women living in retirement communities. Physical therapists should know the main facilitators of physical and barriers to PA and use that knowledge when planning PA interventions to influence the women's physical and social environment and to target the intervention to the women themselves. All authors provided concept/idea/research design, writing, and data analysis. Ms Bjornsdottir provided data collection, fund procurement, participants, facilities/equipment, institutional liaisons, and clerical support. Dr --- Facilitators of and Barriers to Physical Activity in Retirement Communities --- Arnadottir and Dr Halldorsdottir provided consultation . Ms Bjornsdottir was a student at the University of Akureyri, Akureyri, Iceland, at the time this research was completed in partial fulfillment of the requirements for her Master of Science degree in health sciences. Ms Bjornsdottir presented a poster on this research at the 16th International Congress of the World Confederation for Physical Therapy; June 20 -23, 2011; Amsterdam, the Netherlands.

Older people are being encouraged to be physically active for as long as possible as a preventive measure against disease and functional decline. It remains, however, uncertain how living in a retirement community affects physical activity (PA). Objectives. This study was conducted to understand the PA experiences of older women living in retirement communities and what they experience as facilitators of and barriers to PA.The study was qualitative and guided by the Vancouver School of doing phenomenology, a unique blend of phenomenology, hermeneutics, and constructivism.Participants were 10 women, aged from 72 to 97 years (meanϭ84 years). In-depth interviews were conducted, recorded, transcribed, and thematically analyzed.A model was constructed with 3 main themes: (1) the women themselves, including their experienced health condition, individual aspects of functioning, and various personal factors; (2) the physical environment; and (3) the social environment. These main themes all include subthemes of experienced influences on PA, such as health, design of housing and environment, and local culture. These influences could both facilitate and hinder PA, depending on the context. The facilitating effects of good outdoor areas, accessible physical training facilities, a familiar neighborhood, and finding joy in PA were clear in the study. The barriers included worsening health, a colder climate with ice and wind, and lack of a PA culture within the retirement community. Conclusions. An older woman's residence may strongly influence her ability and motivation to be physically active. Physical therapists should acquaint themselves with the facilitators of and barriers to PA of women within retirement communities and use that knowledge to influence the physical and social environment and to target PA interventions to the women themselves.

I. INTRODUCTION Plurality in social and religious life in Indonesia often creates social problems without proper management. This phenomenon is indicated by the emergence of a number of conflicts that are suspected to be rooted in religious differences. This condition is the opposite of the expectation as contained in the teachings of each religion that religious practice aims to build social harmony, both internally among religious adherents and externally among religious adherents different. This is in line with Durkheim's expression who argues that religion plays an important role, namely as an integrator of society. Referring to Yewangoe, that religion is a system of interpretation of the world that provides an articulation of self-understanding and the place and duties of human beings in society in the universe. Religion in the functional definition as the core of society that is constitutive of society. Amran reveals that religion contains human belief in supernatural powers that seem to accompany humans in a broad scope of life. Religion in relation to this has values for life individually as well as in relation to social life which has an impact on everyday human life. In interaction with other individuals in society, religion helps humans determine their roles and responsibilities as members of the human family. One of the main things that religions offer to humans is peace. Peace with oneself, peace with others, peace in society, peace in this world, even peace in the hereafter . In this regard, in a smaller scope, namely in humans, at the most personal level, religious teachings help humans to humanize themselves. At this level, the embodiment of religious teachings can be used as a guide for his life and for formulating his goals in life, both in the physical aspect and in the spiritual aspect. By having a steady form of belief they are able to form optimism in maintaining their vitality. In line with that, Tim Penyusun argued that the teachings, especially in the teachings of Hinduism have alignment goals with national development, namely to balance inner and outer life. On the other hand, when pluralism in religious social life is not managed properly it tends to create conflicts based on religious practices. This phenomenon is the other side of religion as expressed by Marx as a disintegrator in a society. If you think about cases that arise like this, it cannot be separated from the large role of the interpretation of the people towards the teachings of the religion they adhere to. In responding to the emergence of various behaviors in the midst of religious life, the basis is the interpretation of the text used as a source of behavior guidelines. In looking at social conflicts, especially those in the realm of religion in Indonesia, according to Soetrisno that religion as a vehicle that is very effective in mobilizing the masses. But, the effectiveness of religion as a cause of conflict depends on the conditions experienced by a society. Religion will easily become mobilized to achieve negative goals, such as causing conflict, if people experience high economic and political powerlessness. On the contrary, in social life according to the views of sociologists of religion, a religious symbol that is accepted and believed as a point of similarity in faith or beliefs of all members of a religion gives an important influence on the establishment of cohesive relationships between its adherents. On the other hand, the gradation of religious group selfassessment runs parallel to the beliefs of its members in a symbol that is believed to be a concrete statement from the highest reality positive group to carry out His work. In the realm of religious social life, a symbol of brotherhood which is not in the form of an institution but a person who has contributed to his people, turns out to promote a sense of community cohesion to the highest level . In synergy with that, the ritual practices carried out by the Sasak-Islamic community and the Bali-Hindu community in Sarasuta holy place represent awareness to build social cohesion. They use the sacred place of Sarasuta in the dimension of faith to implement their belief system with specific goals in their life and in the social dimension they realize social relations. A harmonious relationship between adherents of different religions is a must. This can be done by bringing people of different religions closer and communicating so they can understand each other. Such communication can occur in the form of ritual communication. This phenomenon is similar to that carried out by followers of Islam and Hindus in the sacred area of Sarasuta, Lingsar subsubdistrict, West Lombok Regency. In that place, two adherents of different religions carry out religious ritual activities together, namely between Hindus and Muslims. This has happened since historical times, namely during the reign of the Karangasem Bali Kingdom in Lombok. Adherents of Hindus carry out religious activities according to the procedures practiced by Hindus, while the Sasak-Islam community carry out rituals of traditional customs passed down by their predecessors. The ritual communication of the multireligious community embodies tolerance as the basis for building social harmony. Second, communication that occurs between Bali-Hindu and Sasak-Islam does not only occur verbally but also in nonverbal aspects. Verbal communication is done using utterances that are usually done when communicating verbally. Verbal communication is carried out using language understood by each party. There are two languages used as a means of communication between Bali-Hindu and Sasak-Islam, namely Bali language and Sasak language. Bali language is the language used in conducting conversations among Balinese people. Likewise, the Sasak language is the native language used to carry out conversations with fellow Sasak people. Because the relationship between the Balinese and the Sasak people in Lingsar Village is very close, they learn from each other the languages spoken by different ethnicities. In this case, the Balinese who already have Balinese as their daily language of conversation also learn Sasak so they can communicate with the Sasak people. The non-verbal language used in the communication process between Bali-Hindu and Sasak-Islam do not use conversational language. Non-verbal language used such as codes, signs, or symbols, or other forms of sign language that they have agreed upon. They use nonverbal language in certain activities and not necessarily in everyday life. This non-verbal language is widely practiced in activities that have a cultural nuance, both those carried out by the Balinese and the Sasak people in relation to preserving ancestral traditions. In this regard, Wirawan suggests that a number of cultural events, especially in the arts, are carried out by Balinese and Sasak people in Lombok using local languages that are easy for the two ethnicities to understand. This can be seen in the art activities involving Balinese and Sasak artists. Third, the livelihood system that was worked on by the Bali-Hindu and also by the Sasak people who were Muslim at the beginning of the Balinese residing in Lombok, especially in Lingsar Village was almost similar. The similarity lies in the livelihoods that they are mostly engaged in as farmers. Based on this, they live side by side and at the same time help each other when they encounter problems related to carrying out the profession as farmers. The similarity in carrying out these professions has been the glue in realizing good relations between the Bali-Hindu and the Sasak people who are Muslim since historical times. They communicate in solving problems in everyday life, especially in agriculture. Referring to Maretha that the social relations between the Balinese and the Sasak people are very close, one of which is because they have a loan shark kinship system. This is shown by the people in the Pemenang area in Lombok. In line with that, Suprapto also revealed that Sasak-Islam and Bali-Hindu communities have "quotidian bonds" that are implemented to build social cohesiveness in everyday life. Fourth, based on the results of observations in the field it was found that the cultural system instilled by the Bali-Hindu community in Lombok has similarities with the cultural system applied by the Sasak-Islam people. The similarity of these cultural aspects can be seen from various aspects, such as in customary dress procedures, ways of realizing ancestral traditions, in ritual practices, in socializing procedures, in maintaining ethics, in respecting ancestral traditions, and what there are similarities in these cultural aspects apparently in the past there was an exchange of several cultural aspects so that there was an element of resemblance. One of the similarities in the cultural aspects of dress can be seen to date, that the traditional clothes of the Sasak ethnic and the traditional clothes of the Balinese ethnic do not seem much different. In cultural activities such as weddings, traditional activities and others, the Sasak people display clothing that is similar to the traditional clothes worn by the Balinese people. This shows that in terms of the cultural aspect, the Balinese, who are Hindus, and the Sasak people, who are Muslims, have established a communication so that similarities in the aspects of dress can occur and can still be maintained today. There are a number of factors that indicate a close relationship between Bali-Hindu and Sasak Muslims, especially in the cultural aspect which is closely related to efforts to create togetherness and strengthen unity. Based on this, the following describes the form of ritual communication between Bali-Hindu and Sasak-Islam at the Sarasuta holy place, Lingsar Subdistrict, West Lombok Regency. The ritual communication implemented in the belief system carried out by Bali-Hindu and Sasak-Islam in the sacred area of Sarasuta, Lingsar subdistrict, West Lombok involves ritual practices according to their respective beliefs. Ritual practices carried out by the Hindu community at the Sarasuta holy place as a form of devotion to Supernatural and all of His manifestations that reside in that place. The place used to perform rituals in the uppermost area is called jeroan. The jeroan area is also called uttama mandala consisting of several sacred buildings which in Hindu society are called pelinggih. The pelingggih are a symbol of Supernatural's palace and a manifestation of Him who is believed to reside in that place. The peak of the ceremony performed by Hindus is called odalan or pujawali which comes once a year. The pujawali ceremony in the jeroan area falls on the purnama sasih kedasa . The pujawali ceremony was attended by Bali-Hindu who live around Lingsar Village and those who come from outside Lingsar Village. As for the means brought by the Balinese in carrying out the pujawali ceremony or other ritual activities, they are brought directly from their place of origin which is then used as a means of carrying out the ceremony. This is as expressed by Inaq Icah that Balinese people also come to this place to perform ritual activities. Balinese people who come here carry rituals with the aim of praying in the temple area which is located at the top. Balinese people who come here to perform rituals by bringing offerings in the form of offerings, then they are due. Based on the statement conveyed by the informant above, it was revealed that the Balinese who came to carry out religious activities in the sacred area of Sarasuta brought directly the required ritual equipment. If the person who is going to carry out the prayer they bring prayer tools in the form of simple ritual forms. Meanwhile, when there is a pujawali ceremony, the type of ritual means that is brought is different from the type of ritual when they come to just pray. In the other hand to the case when the Sasak people came to the Sarasuta sacred area they performed ritual activities in a place at the bottom of the Sarasuta holy place. This is as stated by the informant Inaq Icah that while the Sasak people who come here to carry out ritual activities are located at Kemaliq which is located at the bottom. In the past there were also Sasak Muslim people who came to this place to carry out ritual activities such as circumcision ceremonies. Based on the statement conveyed by the informant above, it is known that apart from Balinese Hindus who come to the Sarasuta sacred area to carry out ritual activities, there are also Sasak people who come to that place. Even though they come to the same place, the Sasak people who come to perform the ritual are not in the temple section but they do it in the lower part, which is in the kemaliq. The Sasak people who came to this place in the past generally performed ritual activities, such as sunatan . This shows that the Balinese and Sasak people in carrying out religious activities in that place already have their respective places so that they do not mix in carrying out ritual activities. Rituals related to manusa yadnya which are performed in the sacred area of Sarasuta, such as ceremonies given to babies. Based on the data obtained in the field, the manusa yadnya ceremony which was carried out at that place was otonan. This is as stated by Inaq Icah that some time ago there were Balinese people who came here with the aim of performing "ceremonies on babies" according to their traditions. Based on the results of the interview above, it is known that the Balinese who are Hindu in carrying out ritual activities are part of the traditions passed down by their ancestors since the past. This tradition is related to the ceremony given to their baby. In the practice of Balinese religious life, the ceremony given to the baby is part of the manusa yadnya ceremony. The ceremony is a way to purify the baby from the impurities that have been brought from birth. Through the manusa yadnya ceremony the aim is to purify the baby from the impurities inherent in him abstractly. The ceremony aims to improve the spiritual quality of the child so that it is hoped that he will become a suputra children . The Suputra children are children who want to follow the teachings taught by Hinduism and stay away from mandated prohibitions so that these children will be useful in the future. Based on the interviews above, it can be seen that the Balinese and the Sasak people, especially in Lingsar Village, West Lombok Regency, have such closeness that they seem like brothers. They no longer consider ethnic differences to be a barrier in establishing brotherly relations. Likewise, the difference in religion that they profess is also not a gap to create brotherhood. Through the implementation of rituals in accordance with their respective traditions, both the Hindu Balinese and the Muslim Sasak people are able to show attitudes of harmony. This also shows that there have never been serious problems between the Balinese who are Hindus and the Sasak people who are Muslims. It seems that the differences are limited to the colors that knit the beauty of life between them. Based on the explanation above, there is a very important point to point out related to --- Ritual Communication as Cultural Representation of Interfaith Communities Ritual communication in the cultural system that occurs between the Balinese who are Balinese people who come and live in Lombok live in groups with other Balinese people. In the life of this group, the Balinese embody the cultural system as practiced in their place of origin in Bali. Even though this cultural system is implemented by Balinese people who are in Lombok, in practice not all Balinese culture is embodied in Lombok. There are several aspects of Balinese culture that have adapted to their new place in Lombok. Apart from being caused by the natural environment which is not exactly the same as in Bali, this adaptation is also due to the cultural influence of the Sasak people. Based on this, there are some differences in practice between Balinese culture practiced in Bali and Balinese culture practiced in Lombok. The Balinese cultural system which has been influenced by the Sasak culture has characteristics that are not the same as those in Bali. These characteristics are like the mutual cooperation system of the Balinese people in Lombok who know the sidhikara system. While the Balinese who practice Balinese culture in Bali, the mutual cooperation system is accommodated by the banjar system and pakraman Village. The sidhikara system seems to be a priority in accommodating religious activities that involve large numbers of people. Some sidhikara systems are formed based on clan ties and some are formed based on kinship ties. The sidhikara social system in Hindu society in Lombok has been used since historical times as a vehicle to accommodate socio-cultural and religious activities, especially among Balinese Hindus. According to Kembarawan that the sidhikara social system owned by the Balinese people in Lombok has been built since historical times. The sidhikara social system is used as a medium for building social bonds among Balinese people in the implementation of Hinduism. On the other hand, the Sasak people also have a cultural system that they inherited from their ancestors from the past. The cultural system applied by the Sasak people is in some ways similar to the cultural system applied by the Balinese people. There are several cultural elements that have similarities so that this strengthens the assumption that the people of Bali and Lombok have exchanged cultures with each other. One of the most frequently found examples relates to similarities in these cultures, such as traditional dress patterns, language patterns, patterns in the art system, and so on. With regard to communication, Chandra examines the existence of dynamics in social communication between the Balinese and the Sasak people. The dynamics of social communication bring positive and negative impacts. In relation to the cultural practices implemented by the Balinese who are Hindus and the Sasak ethnic who are Muslims in Lingsar village, West Lombok, according to the results of field observations and also the results of interviews show similarities. These similarities are actualized in cultural practices that are carried out together. This can be seen in the sacred area of Sarasuta where the Balinese and the Sasak people each practice a cultural system that is owned by each ethnic so that there are similarities. Cultural practices implemented jointly in the sacred area of Sarasuta, such as in the tradition of purifying newborns. Balinese people who believe in traditions passed down from their ancestors practice quarterly rituals, otonan, or other activities inherited from their ancestors. Likewise, the Sasak people also perform rituals, such as circumcision and hair cutting ceremonies in the sacred area of Sarasuta. This is as stated by Mahrahman stated that the past, the Sasak people often came here to carry out activities related to their ancestral traditions, such as carrying out hair-shaving ceremonies and holding slametan ceremonies. But lately the Sasak people have begun to rarely come here to carry out activities related to their ancestral traditions. Based on the expressions conveyed by the informant above, it was revealed that in the past the sacred area of Sarasuta was not only used by Hindus to carry out activities related to cultural practices and the implementation of the Hindu religion, but also used by the Islamic community to carry out traditional activities related to continuation of ancestral traditions. Even though the Sasak people are Muslim, they also have a belief in rituals as part of transmitting the cultural values of their ancestral heritage. There are several forms of ritual practiced in the area as stated by the informant above, such as the slametan ceremony and the hair-shaving ceremony. This also implies that the Sasak people also practice ancestral traditions just as the Balinese practice their culture. The relationship between the Balinese people who are Hindus and the Sasak ethnic who are Muslims from the past until now for the Lingsar area and its surroundings can still be maintained. In implementing cultural aspects between the two ethnicities of different religions, they create a mutual understanding of one another. This is as expressed by Mahrahman that the relationship between the Balinese and the Sasak people has always been very good. Recently, this good relationship can still be maintained. There are no urgent issues that have caused polemics between the Hindu community and the Islamic community in the Lingsar village area and its surroundings. The expression conveyed by the informant above implies that between the Balinese and the Sasak people a harmonious relationship has been built since historical times to the present. In this connection also can not be separated from the communication that occurs between the two ethnic groups of different religions. This phenomenon is based on the logic that in forming social relations the aspect of communication plays a very important role. The communication that occurs between the two ethnic groups of different religions involves both verbal and nonverbal communication. Verbal communication that occurs between the Balinese who are Hindus and the Sasak ethnic who are Muslims occurs through oral utterances. The communication generally uses the medium of spoken language. In this regard, the Balinese living in the Lingsar sub-subdistrict and its surroundings understand Balinese and Sasak well. When they communicate with Balinese people they use Balinese as the language of instruction. Likewise, when the Balinese communicate with the Sasak people, they tend to use the Sasak language as the language of instruction. The same thing also happened to the Sasak people who know two languages, namely Sasak and Balinese. When the Sasak people communicate with the Sasak people they use the Sasak language as the language of instruction. If the Sasak people communicate with the Balinese there are two possibilities. First, if there are more Balinese people they use Bali language as the language of instruction. Second, if there are more Sasak people they use Sasak language as the language of instruction. --- Ritual Communication in the Perspective of Religious Tolerance The ritual communication that occurs between Balinese Hindus and Sasak ethnicities who are Muslim in the sacred area of Sarasuta is communication related to activities that involve the participation of many people. There are a number of activities carried out by the Hindu Balinese and the Sasak ethnic who are Muslim around the sacred area of Sarasuta, such as mutual cooperation activities, activities for building facilities and infrastructure, activities related to the agricultural system, and other activities that involve the participation of many people. Activities related to gotong royong carried out by the two ethnic groups of different religions in historical times were carried out together both when they worked within the internal environment of their fellow ethnicitiesmen and which involved inter-ethnic activities. These attitudes of togetherness have been well maintained so that good communication is established among them, both internally among the same ethnic and externally between different ethnicities. These cooperative qualities build a closeness between them so that they consider themselves as brothers. This is in line with Wirawan that the people of Lombok since historical times have shown inter-religious and cross-ethnic social interaction. There are many activities that involve the active role of cross-ethnic and multi-religious communities, such as the customary tradition of memarek in North Lombok. The nature of mutual cooperation between Balinese and Sasak ethnic groups creates solidarity so that they can be united in carrying out social activities. Mutual cooperation activities carried out jointly between the two ethnicities of different religions contain communicative aspects, both verbally and non-verbally. Communication that occurs verbally is of course related to the delivery of messages, both those carried out by the Sasak people and the Balinese people. The verbal message delivery system is often carried out in activities that they carry out together. In reality they communicate using languages that are mutually understandable to those involved in the communication process. The verbal language is horizontally used in the communication process internally among the same ethnic group as well as externally with different ethnicities. The same thing also happens when carrying out activities in infrastructure development that they use together. Starting from the planning process will make an activity both building and repairing infrastructure has already occurred a communication process. The communication is done verbally. In analogy with the above, ritual communication is also carried out in activities related to the agricultural system carried out by the Hindu Balinese and the Sasak ethnic who are Muslim, which involves conveying messages in the realm of livelihood they are engaged in as farmers. Observing the historical background, the Balinese people who came to Lombok, especially to Lingsar after the Karangasem Kingdom succeeded in expanding to Lombok, were predominantly farmers by profession. In doing farming, the Balinese people seem to have an advantage in terms of skills. Because of that the Sasak people try to follow the patterns actualized by the Balinese people. In this case there is also verbal communication between the Balinese and the Sasak people in an effort to improve agricultural output in a better direction. Ritual communication within the realm of the agricultural system is also inseparable from the ritual traditions carried out by Balinese Hindus. This tradition is implemented in making rituals that are presented in connection with efforts to improve the quality of agriculture. In line with this, the Sasak ethnic community also tries to follow the ways practiced by the Balinese people. This is where the uniqueness lies in that the ritual communication that occurs which involves many people cannot be separated from the religious practices carried out by the Balinese people. The ritual communication in relation to the realm of the profession as a farmer also involves aspects of supernatural power which are believed to have an influence on the agricultural products they produce. This is based on the idea that these supernatural powers control the universe so they need to be given respect. In addition, they pay respects by using ritual means. This shows that the existence of ritual communication in the realm of the livelihood system is a reality that concerns the relationship between humans together with power entities in the universe. The ritual communication in the horizontal dimension, between the Balinese who are Hindus and the Sasak people who are Muslim can be seen from the relations between the two ethnic groups who are of different religions. They both came to the place with the aim of carrying out ritual activities, behind which communication also took place, especially verbal communication between the two ethnic groups. The communication process created closeness between the two ethnic groups. In line with that they at the same time melt the barriers that limit the differences between them. The two points of communication, both vertical and horizontal communication that occur in the realm of belief systems practiced in the sacred area of Sarasuta, Lingsar Subdistrict, West Lombok Regency, have a positive dimension to build harmony between the two different ethnicities and the belief systems they adhere to are also different. In line with that, Jayadi reveals that the traditions carried out by the Sasak and Balinese people in Lombok are a vehicle for realizing harmony. This can be seen in the topat war tradition carried out in Lingsar which shows the values of tolerance. --- IV. Conclusion Based on the results of this study, three findings were found as conclusions in response to the focus of the problems posed.

This article aims to explain the implementation of ritual communication carried out by the Balinese-Hindu and Sasak-Islamic people at the Sarasuta holy place, Lingsar Subsubdistrict, West Lombok Regency from the perspective of religious tolerance. The method used in producing this study is interpretive qualitative using a case study model. Based on the research results found three findings. First, ritual communication presented by followers of two different religions, namely Sasak-Islam and Balinese-Hindu as the implementation of a belief system to improve the quality of life. Second, the Muslim-Sasak community carries out ritual communication as the implementation of the customary traditions inherited by their predecessors, while the Balinese-Hindu community implements ritual communication as the continuation of Hindu religious culture. Third, the ritual communication of people of different religions in the Sarasuta holy place in the social dimension tends to strengthen religious tolerance.komunikasi ritual, adat istiadat, budaya religius, toleransi, Sarasuta, Penelitian ini bertujuan untuk menjelaskan pelaksanaan komunikasi ritual yang dilakukan oleh masyarakat Bali-Hindu dan Sasak-Islam di tempat suci Sarasuta, Kecamatan Lingsar, Kabupaten Lombok Barat dalam perspektif toleransi beragama. Metode yang digunakan dalam menghasilkan penelitian ini adalah kualitatif interpretatif dengan menggunakan model studi kasus. Berdasarkan hasil penelitian ditemukan tiga temuan. Pertama, komunikasi ritual yang dihadirkan oleh pemeluk dua agama yang berbeda, yaitu Islam-Sasak dan Hindu-Bali sebagai implementasi dari sistem kepercayaan untuk meningkatkan kualitas hidup. Kedua, masyarakat Islam-Sasak melakukan komunikasi ritual sebagai implementasi dari tradisi adat yang

Background College students face a disproportionate share of health disparities, including poor sleep health [1][2][3][4], risky financial behaviors, such as credit card debt, health behaviors, and [5][6][7] low health literacy [8], including low sexual and reproductive health literacy [9][10][11][12], higher basic needs insecurities [13,14], as well as poor mental health outcomes [15][16][17][18]. For example, in an assessment of over 7600 college students from six different universities, Becker et al. noted that a majority of participants met the criteria for poor sleep, and such outcomes were associated with poor mental health status as well [1]. Likewise, a review of existing literature on HIV risk behaviors among college students noted that not only did a majority of participants have multiple sex partners, both safe sex communication and practices were also limited [7]. Further, in an assessment of basic need insecurities among college students, researchers have found that being food, finance, and housing insecurity were cumulatively related to increased odds of anxiety, depression, lower health status, as well as poor academic performance [13]. Another key emergent area of disparity noted among college students is that of discrimination. The American Psychological Association notes that discrimination is an "unfair or prejudicial treatment" of population based on shared characteristics, such as race, gender, age, sexual orientation, etc. [19]. Although prevalence studies on the various types and sources of discrimination among college students population remain limited, the empirical evidence notes that among African American college students, experiences of discrimination were associated with sleep problems [20]. Likewise, the literature notes that Hispanic/Latino college students with experiences of discriminations are more likely to develop symptoms of posttraumatic stress, as well as risky behaviors, such as alcohol use [21]. In addition, an assessment of female graduate students in science programs have also highlighted experiences of sexism, sexual harassment, gender rolebased stereotyping, as well as microaggressions [22]. Although such literature highlights the prevalence and the burden of discrimination among college students, most are often limited to assessment of experiences of discrimination based on racial/ethnic identity and/or colorism and sometimes gender norms; delineation of types and sources of such discrimination remain limited as well. For example, recent evidence highlights the putative emergence of workplace discrimination among younger populations [23]. Likewise, studies among international students have noted a differing perception of discrimination based on European immigrant versus non-European [24]. Understanding the types of such experiences college students face, the source of such stressors, and how that, in turn, the impacts on mental health is imperative due to the critical transition phase of adapting to new environment, forging friendships, developing coping skills, etc. [25,26]. As such, the goal of this study was to assess the prevalence of discrimination experiences, association between such experiences with both physical and mental health, and types and sources of such discrimination experiences among college students at a Hispanic and minority serving institution. --- Methods This study used an explanatory sequential mixed-methods approach, with quantitative assessment followed by that of qualitative. In this approach, qualitative data are utilized to explain, interpret, and provide further clarification of the quantitative results [27]. Combining the two methods in this sequence further allowed us to explain the patterns and associations noted in survey responses and, in turn, provide unique insight into emergent themes related to discrimination experiences among college students. In this study, during the first phase, quantitative analysis of an annual student health assessment was conducted. Students, aged 18 years or older, were recruited from general education courses to ensure inclusion of a variety of majors and extra credit was provided as incentives. The annual survey collects data on various health and behavioral outcomes, including alcohol and tobacco use, sleep health, mental health, experiences of discrimination, and sociodemographic characteristics. In this study, we selected participants who identified as racial/ethnic minorities . In the U.S., ethnicity is primarily defined as Hispanic/non-Hispanic, while racial groups may include one or more of the following: African American, Asian American, White, etc. All participants who were currently enrolled, were at least 18 years of age, whose classes shared the survey, and who provided written consent were selected in the study. We did not collect any parental or family data. However, a majority of the participants at the institution are first-generation college students on financial aid. We further evaluated experiences of discrimination, assessed through the Everyday Discrimination scale [28], as well as the presence of psychological distress, evaluated using the Kessler-6 scale [29]. In addition, food security status, a marker for poverty, was assessed using the U.S. Department of Agriculture six-item questionnaire [30]. Finally, self-reported general mental and general physical health statuses were also included, similar to questions in the California Health Interview Survey, in addition to age, sex, and racial/ethnic identity. Due to most of the study population being Hispanic and, thus, low frequency of other racial/ethnic groups, we dichotomized the race/ethnicity variable by ethnicity only to ensure protection of unique data combinations, per our ethical review board guidelines. A total of 308 participants were included for the quantitative assessment. All quantitative data were analyzed in SPSS version 28 . First, descriptive statistics were conducted to assess the mean discrimination score, as well as prevalence of psychological distress, low mental health status, and low physical health status. Next, bivariate analyses with alpha = 0.05 were used to assess whether mean discrimination differed by serious psychological distress status, mental health status, physical health status, and sociodemographic characteristics. To help provide insight into the various types and sources of discrimination, we conducted qualitative analysis. For this second phase, students aged 18 years or older from five general education laboratories were recruited to ensure a diversity of majors. Those who consented to participate were given extra credit as an incentive. Further, due to the sensitive nature of the questions asked in shared spaces via focus groups, we did not analyze demographic characteristics, but used purposive sampling to ensure the sample size was reflective of the student population from the quantitative phase. Given that a majority of the students are considered vulnerable population the researchers refrained from one-on-one interviews and instead opted for a focus group to allow a more relaxed peer-based discussion. As a result of reaching theoretical saturation, we included responses from a total of 18 students. Semi-structured interviews in a focus group format were conducted. Such open-ended questions included whether students experience discrimination of any sort during their daily life, and if they have, detail the types of experiences and sources, as well as how that impacts their mental health. For participants who did not directly experience any discrimination, they were asked to describe what they have seen others experience instead. All responses were electronically recorded and transcribed verbatim, followed by de-identification of data per ethical board approval guidelines. Such qualitative responses were then thematically analyzed to identify emergent themes in a five-step process [31]. First, two independent researchers read each focus group interview transcript at least two times and added initial concepts as marginal notes. Next, given that our focus was on discrimination, the initial coding utilized a theoretical thematic approach, versus inductive. Common words and phrases that were related to experiences of discrimination were highlighted. This was conducted independently by two researchers and compared and contrasted until a consensus was reached. Once a list of identified codes were finalized, we reviewed each code and grouped into common themes, with consensus reached upon discussion. We next assessed each identified preliminary theme against Maguire and Brid Delahunt's six-question checklist were selected to provide context of emergent themes. --- Results In our quantitative phase, a total of 308 participants were evaluated. As shown in Table 1, a majority of the study population were females , aged 18-20 years , and Hispanic/Latino . Further, 48.4% reported low physical health status, defined as very poor/poor/average, 45.1% reported low mental health status , 21% reported serious psychological distress, and 37.4% were food insecure. Further, the mean everyday discrimination score of the entire study population was 2.10. We then compared everyday discrimination score by stressors to evaluate the potential compounding role. Results show that mean everyday discrimination score was significantly higher among those with low physical health status, as compared to those with excellent/good physical health status and those with low mental health status versus those with excellent/good mental health status . Likewise, such mean discrimination score was significantly higher among those with serious psychological distress, versus those without . Further, participants who were food insecure reported a significantly higher mean discrimination score, when compared to their food secure counterparts . We also evaluated the commonly cited reasons participants felt they were discriminated against. As shown in Table 2, the most prevalent reason reported was appearance , followed by race/ethnicity , skin color , and gender identity . Our qualitative results identified two central themes related to discrimination, including expectations, socio-demographic, and acculturative stress, as well as several emergent subthemes as participants described a plethora of sources and types of experiences of discrimination in their daily lives, which further provide insight into the association noted between discrimination and poor mental and physical health among participants. Interestingly, when assessing experiences of discrimination in daily life, a common theme was that of norm or expectation. For example, among Black/African American participants, the underlying notion was that as a person of color experiencing discrimination is routine. On the other hand Hispanic/Latino participants noted more detailed encounters they were often surprised at the experiences based on stereotypes, aggregation, and generalization based on expected behaviors/mannerisms. "They judge us and see us as the same person . . . we may look the same, but we're completely different." "My dad . . . likes lowrider cars and we're like driving . . . we got pulled over, like we weren't doing anything, but my dad got slammed like to the hood of the car . . . 'cause they said he was gang affiliated, but my dad has never even been in a gang, but just because of like the way he looked" "My boyfriend is white. He's like why are you so Mexican? I could find someone better than you." When assessing specific sources and types of discrimination, further theme of sociodemographic-based discrimination emerged. For example, workplace discrimination , primarily based on younger age, as well as gender stereotypes were the most prominent theme among study participants. " . . . it sucks to know that someone is undermining a lot of the trainings that I went through and the experience that I got." "I think it's because we are millennials. I'm guessing that's what it is . . . that we're not as competent compared to someone from another generation." "I wish I could be seen as a professional and not just as seen as . . . too young to teach them . . . " "Just being a woman when it comes to like . . . heavy lifting, I kind of see guys tend to not like, pick me because I'm small. For example, I work at the gym, so it's like lifting treads and all that it's like let's send the boys to do it." Another common theme related to workplace discrimination was related to elitism, and based on educational attainment, discipline, as well as income. Participants noted that employees with higher rank often belittled others who did not hold a similar position or higher degrees. Responses show that choices in academic fields have also been discriminated against. Such experiences of discrimination that participants experienced further led them to quit their jobs and the associated stressors. "I work with a lot of doctors, nurses . . . they [have] higher education. I feel like sometimes I'm looked down upon." "Oh, well what are you doing? And I'm like oh, I'm doing public health and they're like oh, well that's not interesting." " . . . people with money they see all the other people a lot lower." Furthermore, another emergent theme was that of acculturative stress, when the process of adapting to the norms of U.S. resulted in a negative impact on both domestic and international students. For example, most Hispanic/Latino and Black/African American participants noted experiences of colorism from within the family, where several participants noted that family members who were of darker complexion were often mistreated by others in the family of lighter complexion. "My Mexican side of the family will be like . . . You guys are black [referring to skin color and not race] anyways . . . I've kind of felt different in a sense . . . we've always been like kind of kicked to the curb." "I have two little cousins and they're both the same age and one is like blond light-colored eyes and the other one is like darker, you know just a little bit tanner and he [grandfather] like willingly shows like he prefers like the lighter one." Furthermore, participants also noted that within family, language-based discrimination occurred, where those not speaking a traditional language fluently often resulted in being called names or felt isolated. For instance, several participants described situations where having an American accent when speaking their family's native tongue often resulted in being targeted and felt lack of belonging. "They just started arguing with me like, okay, they were real . . . they're like [I was] trying to be white or something." " . . . you don't belong . . . when I try to speak Spanish . . . so that always kind of made me feel like a sense of loss of identity." Although experiences of discrimination on campus and/or classrooms were not widely reported, among those who did, such experiences were based on being an immigrant, and primarily due to having a foreign accent while speaking English or ethnic-specific stereotypes, which, in turn, participants noted left them with feelings of isolation or unwanted negative attention. "Foreign exchange students sometimes they get looked down upon . . . when they're speaking." "I notice sometimes when I talk to people, they like to point out my accent." "Sometimes I feel a little different in class . . . because my English no good, no one wants to work with me." "One time during class we were choosing groups and I heard people say that [redacted ethnic identity] are lazy and only cheat." Nearly all participants noted that the various forms of discrimination, especially related to work, negatively impacted their mental health. Many noted that such experiences, especially at work, made them question their own skills, abilities, worth, as well as added stressors with long-term feelings of hurt, isolation, and self-blaming. --- Discussion The purpose of our study was to assess experiences of discrimination, how that may influence mental health, as well as delineate the various types and sources of discriminations that such a population face. The results of our explanatory sequential mixed-methods study demonstrate that: experiences of discrimination were prevalent among college students with disproportionate shares among those who were food insecure, highlighting the most vulnerable. This is further clarified in qualitative analysis that highlights socioeconomic status-based discrimination, where participants' education level and degree type at workplace was cited. Additional workplace-related discrimination included experiences based on younger age and gender identity. Furthermore, experiences of discrimination came from within the family based on colorism and having an American accent and from peers based on having a non-American accent, especially among immigrants. The expectation of discrimination, especially among Black/African Americans was also common. Cumulatively, various levels of discrimination and types demonstrate the complexity of the stressors college students experience that can negatively impact mental and physical health of the target population. The literature notes that mothers who experienced racial/ethnic discrimination were also more likely to report household food insecurity and poorer mental and physical health status [32], with similar patterns noted among 154 African American adults in South Carolina [33], and men of a sexual minority status [34]. Although similar studies among college students are limited, our study noted that not only are food insecure participants experiencing higher everyday discrimination, but such discrimination often occurs in areas where students are aiming to gain professional experiences , which, in turn, negatively influences their self-efficacy in work performance. Given that food insecurity is known to lower academic performance [35,36], which, in turn, negatively impacts future employment [37], our results highlight that to optimize workforce development, employer training on discrimination practices based on socioeconomic status remains imperative. Furthermore, our results highlight that a substantial ongoing theme of workplace discrimination based on both younger age, as well as woman/girl gender identity. Such results have significant implications for long-term professional development of college students. For instance, while historical legislation on ageism has focused on discrimination against those aged 40 years or older [38] and research on age-based discrimination among younger populations remains substantially negligible, there is a rising pattern in the empirical evidence that young adults face difficulties securing employment due to perception of lacking experience [23,39]. In our study we noted that even participants with substantial certifications and experiences often felt discriminated against due to either being younger in age or lacking higher education . This double-jeopardy of bias, resulting from societal perception that age or higher education alone equates to qualification, can posit a significant burden in the labor market, especially during the COVID-19 pandemic that is creating a global labor shortage [40,41]. In addition, participants further noted that their feminine gender identity was also associated with experiences of discrimination, independent of their qualifications; a pattern further noted in the literature as a common experience of women [42]. Cumulatively, the qualitative results of our study further clarify why a majority of participants in the quantitative assessment noted appearance as the most prevalent form of discrimination, as both looking younger, and gender were further reported as common workplace-related sources of discrimination. As such, legislation and policies that promote workplace training on qualification assessment beyond that of age or degree alone, and instead emphasizing competency, relevant experiences, etc., are needed. Likewise, promoting resilience among college students through career advancement workshops may provide the needed self-efficacy for recent graduates to self-advocate [23]. Furthermore, a unique theme noted in our study was family as a source of discrimination, especially based on colorism and having an American accent when speaking the family's native language. Colorism results in advantages and privileges for those lighter skin, when compared to those of darker skin within racial/ethnic minorities [43]. Studies on colorism within the family, however, show inconsistent results. For example, when assessing discrimination based on skin tone/color among African Americans, results show that while families and media plays a critical role in developing and sustaining perspectives of colorism [44], colorism within family may either be limited or may not play a critical role in experiences of discrimination or mental health [45,46]. On the other hand, colorism has shown to play a role in employment among African American communities, with studies noting African Americans with light skin tones having higher ability to find employment [47]. Similarly, among the Hispanic/Latino population, the role of media in promoting colorism has been noted in the literature [48]. Our study, however, adds to this body of evidence by providing affirmation on the experiences of colorism that darker-skinned racial/ethnic minorities face within their families and resulting in feelings of not belonging and isolation. In addition, our results provide insight into the role of accents and the catch-22 that racial/ethnic minority college students face. For instance, while having an American accent while speaking a native language within one's family was related to experiences of discrimination, isolation, and sense of not-belonging, having a non-American accent, on the other hand, was a source of accent-based discrimination among peers. Although limited, the literature notes the prevalence of accent-based discrimination among international students and the negative burden of mental health [49,50], as well as interracial othering among Asian Americans [51]. Our results demonstrate that the type of accent-based discrimination differs among racial/ethnic college students depending on the audience, with contradictory stressors from family versus peers. Although alleviating accent-based discrimination is complex, involves historical and cultural basis, as well as normalization of mocking non-American accents in media [52,53], there remains a critical need to address such linguistic racism [52] as an integral part of anti-racist movement. Campus-based initiatives that promote course content, such as video lectures, from linguistically diverse professionals may provide a simple and yet effective pedagogical initiative to create more inclusive practices in the classroom. Likewise, resiliency building among students to address experiences of discrimination within a family and the ability to defer from maladaptive coping mechanisms may be beneficial. Finally, a concerning pattern noted in our qualitative assessment was the expectation of racism, especially for Black/African American college students. Herein lies opportunities for institutes of higher education to be active in their diversity, equity, and inclusivity initiatives through integration of culturally responsive and social justice pedagogy [54,55], in turn promoting the next generation of anti-discrimination advocates. The results of the study should be interpreted in the context of its limitations and strengths. Although our study utilized a mixed-methods approach, the cross-sectional nature limits our ability to assess the long-term impact of experiences of discrimination among college-students. Additional dimensions of discrimination were not assessed in the quantitative assessment, especially those stemming from acculturative stress for immigrants, sexual orientation, or others. Nevertheless, our qualitative assessment provided means to lower this bias by providing additional content on experiences of socio-economic and linguistic discriminations experienced by the target population. Cumulatively, our study highlights that college students experience a plethora of discrimination from family, peers, as well as during opportunities of professional development. Optimizing mental health outcomes and overall well-being of the population requires both public health and legislative initiatives that promote the creation of an inclusive environment and resilience building. --- Conclusions Experiences of discrimination are prevalent in the U.S., especially among vulnerable populations. Most of studies related to discrimination, however, focus on racial/ethnic and sometimes gender-based experiences. In our study, we aimed to evaluate both the unique types and sources of discrimination among college students as they often face a plethora of different environments during this transition period. Our results are consistent with the literature in highlighting that discrimination is prevalent among college students. However, such findings further note that such experiences are significantly related to their health outcomes, including mental health and perceived self-worth. In particular, the results note that experiences of discrimination may benefit from assessing social class in America, acculturation-related patterns, as well as whether expecting such stressors can lead to maladaptive coping mechanisms. Workplace training as well as campus-based initiatives are needed to promote inclusive environment for college students. --- Data Availability Statement: Data are not available per IRB guidelines on dissemination. --- --- Informed Consent Statement: All participants received informed consent form.

Background: Experiences of discrimination are prevalent among minority populations, although often empirical evidence does not provide depth into the source and types of discrimination, such as racial/ethnic, gender-based, age, etc. The goal of this study was to assess the unique patterns, types, and sources of discrimination experiences that college students face and explore the role these experiences play in their mental health. Methods: An explanatory sequential mixed-methods study was utilized. Quantitative assessment of college students from a Hispanic and minorityserving institution was conducted to evaluate experiences of discrimination and its association to physical health and mental health (including psychological distress), as well as food insecurity, a marker for poverty. Next, qualitative data were thematically analyzed to further provide an in depth understanding on the sources of such experiences, types of discriminations, as well as the impact on mental health. Results: Results of the quantitative assessment highlight that discrimination was prevalent among the population with a higher everyday discrimination score significantly associated with serious psychological distress, low mental health status, low physical health status, and being food insecure. Further, most of the participants reported that they felt discriminated due to their appearance, with race/ethnicity and skin color as next most commonly cited reasons. Qualitative assessment further demonstrates distinct types of discrimination experiences from a variety of sources. Within a family, colorism and having an American accent while speaking a native language was a predominant source, while among peers, having a non-American accent was a primary source of discrimination experiences. Such experiences based on elitism, gender, and age (being younger) from the workplace were prevalent among the target population. Finally, feelings of isolation, not belonging, as well as negative impact on self-efficacy and self-worth were noted. Conclusion: Experiences of discrimination are prevalent among college students, including from within family and peers. To improve mental health outcomes of such a population, campus-based measures are needed to promote resiliency and social support, as well as community-based initiatives to promote workplace training to create inclusive environments for younger generations entering the workforce.

replace artemisinin-based combination therapy as first-line treatment, this could have severe consequences beyond the region, particularly were resistant parasites to spread to sub-Saharan Africa [8,9]. In the context of these developments, governments of the GMS have set themselves the goal of eliminating malaria from the region by 2030 [1,4]. In the GMS, malaria parasite reservoirs cluster along international borders and around forests [10][11][12]. In these areas, malaria remains endemic in high-risk populations, including mobile migrant workers and forest workers [13][14][15]. With infections often acquired outside villages, forest workers are at high risk of P. falciparum and Plasmodium vivax. Forest workers are also at risk of zoonotic malaria because they come into contact with macaques and other monkey species, which carry simian Plasmodium species, such as Plasmodium cynomolgi and Plasmodium knowlesi [16]. A recent systematic review of qualitative research on malaria-related practices and attitudes of forest-goers in the region highlighted a range of factors that put them at increased risk of malaria: the limited protection offered by current vector control interventions, such as insecticide-treated bed nets and indoor residual spraying , because the major malaria vectors bite outdoors and during daytime; and the limitations of village-based approaches that do not specifically include people who are working in forests [17]. However, there is a lack of research on the nature of forest activities, and the need to understand forest work to better tailor intervention packages [17]. Drawing on in-depth interviews and focus group discussions with forest workers in Siem Pang District, Stung Treng Province, north-eastern Cambodia, this article aims to identify how malaria elimination programmes can be tailored to forest workers' activities, needs and preferences. The article describes forest work and forest workers' attitudes to and experiences of malaria prevention and control tools, and examines the practical challenges of targeting forest workers within malaria elimination efforts. --- Methods --- Setting Stung Treng Province, located in north-eastern Cambodia, borders Lao PDR to its north and west . The province is bisected by the Mekong River and is predominantly rural. With over 14,000 cases reported in 2014 [18], Stung Treng has among the highest incidence of malaria in the country, with Siem Pang District recognized as an area of intense transmission. The Sekong River flows through Siem Pang and seasonal heavy rains can severely affect road access to villages in the surroundings. Siem Pang has a diverse population that includes ethnic minority groups, including Laotian and Kaviet groups. Farming is the main livelihood activity. Forest work is also evident in the area, with logging particularly noticeable. There are densely forested areas in the western part of Virachey National Park and surrounds, which lie to the north of the district close to the border with Laos . Cross border population movement can present challenges to malaria control and there is little systematic description of crossborder movements in this area. --- Respondents As part of a clinical trial evaluating the efficacy of new anti-malarials for P. falciparum , based at the Siem Pang Health Centre, data on risk factors for malaria infection were collected routinely by questionnaire from participants. In-depth interviews were conducted with clinical trial participants who reported visiting forested areas in the six months prior to their most recent malaria infection. Following a participant's recovery and completion of the 42-day follow-up period in the clinical trial, potential respondents were approached by members of a community engagement team attached to the clinical trial to ask about forest-related activities. Focus group discussions were conducted with respondents recruited through snowball sampling to identify other community members who visit forests. Recruitment took place in villages surrounding Siem Pang, where previous activities had taken place to inform local communities about the study underway in the health centre. --- Data collection Data collection tools-an IDI and FGD guide-were developed based on the initial topics of interest drawn from a recent review of research on the forest going and malaria related risk in the GMS [17] and issues identified by field staff at Siem Pang Health Centre: the nature of forest work , familiarity with malaria , malaria diagnosis and treatment, and attitudes to malaria prevention and control measures . Initial IDI and FGD guides were designed in English and translated by a native Khmer speaker and a social scientist/field researcher with 20 years of experience. The guides, which included key topic areas and lists of suggested questions, were designed to be used in a flexible and iterative manner: interviewers would use the appropriate questionnaires to elicit information on the specific topic of interest. The translation of the topic areas and suggested questions were discussed with the team who were also trained on how to use the guide. The guide was then piloted with the first recruited study participants to check for miscommunications and revised as necessary. Interviews took place in villages, typically near to participants' homes. All of the villages lie within Siem Pang District and within the catchment area of Siem Pang Health Centre and typically close to roads and the river. Respondents were interviewed by one of three trained field researchers fluent in Khmer. Interviews took place in Khmer. In the case of respondents experiencing difficulties in expressing themselves in Khmer, translation was sought from other study staff members who were fluent in Laotian or one of the local languages. --- Data processing and analysis With the consent of respondents, interviews were audio-recorded and subsequently transcribed verbatim and translated to English by professional transcribers/translators. The translations were checked by one of the interviewers , who listened to the audiorecordings alongside the translated transcripts to identify inconsistencies. The checked translations were imported into NVivo version 11 for qualitative content analysis. All transcripts were read several times and coded line-by-line using an inductive and deductive approach: the codebook used was initially based on the main research topics. For example, codes were included to capture the different dimensions of forest activities . Subsequently, during the process of coding, themes that emerged from the data were incorporated into the codebook. Patterns across responses were identified for example, regarding the impact of village location or ethnicity on the nature of forest work or experiences with malaria treatment. --- Ethics approval In Cambodia, approval was obtained from the National Ethics Committee for Health Research and from the Oxford Tropical Medicine Research Ethics Committee . All respondents provided informed consent to participate in the study and for the interviews to be audio-recorded. Written informed consent was obtained from all study participants when they were recruited to participate at the Siem Pang Health Centre and subsequently consent was re-obtained verbally immediately before the interviews were conducted in their villages several weeks later. Local authorities and other communities were engaged from an early stage of the clinical trial and the ancillary qualitative research. Before beginning data collection, meetings with local authorities were held to explain the activities and their purpose. Subsequently, major engagement activities were held in study villages to familiarize communities with the research group. There was regular contact between the study team, local health workers and village, commune and district-level leaders. --- Results In-depth interviews were conducted with 19 male respondents, drawn from villages in Siem Pang District and with one from Siem Pang town. The respondents were between 16 and 51 years and identified as Khmer, Kaviet, Khe, and Laotian . Two focus groups were conducted with forest-goers: one in Lakay village with six male respondents aged 17 to 51 ; and one with eight male respondents aged 21 to 44 and drawn from villages around Teak Team . Men were not recruited specifically but all respondents were male because of the nature of forest work. The findings describe the nature of the reported forest activities, and malaria prevention and control-related practices. Attitudes to malaria prevention and control interventions are described. The findings are based on the IDIs and FGDs, with quotations used to illustrate the issues raised in the terms of the respondents. --- Forest visits --- Reasons for visiting forests The respondents visited forested areas to supplement their income from farming or as their main livelihood activity. Focus group respondents cited poverty and a lack of economic alternatives as their reason for working in the forests. The main income-generating activities were collecting wood/logging and collecting forest products, particularly malva nuts. The latter was described as a seasonal activity, whereas logging was undertaken year-round, with some variation depending on access issues . Six respondents mentioned hunting and three referred to fishing as forest-based activities. For a couple of respondents, hunting and fishing were used to generate income but for most they were a way to provide sustenance for their time away from the village. --- Interviewer [I]: Why do you have to go to the forest? Respondent [R1]: For our livelihood. [We have] no other source of income besides going to the forest. I: [R2], may I know why you go to the forest? R2: Because I am poor. I: How about you, [R3]? R3: I am, too. FGD in Lakay Village --- I: What do you do at the forest? R: I collect woods or hunt animals like monitor lizards IDI in Toul Veng village --- Forest destinations Respondents' forest destinations and itineraries depended on their livelihood, particularly whether they combined forest-based activities with farming. In general, respondents described journeys of around a day or more to reach the locations where they log based on the availability of the product of interest. Depending on the distance between locations in the forest, respondents described maintaining a single camp or moving camp. Unlike farming which allows us to cultivate at the same place, we have to go to a new area when no more products are available in the same area of the forest. --- IDI in Lakay Village --- Frequency and length of forest stays The total time spent in forested areas varied depending on the nature of activities, from several days to 6 months, with a frequency of 2 to 20 times per year. The dry season was considered by some as the more popular time to visit the forest because roads were less muddy and more easily passable than during the rainy season. I: How many days do you usually spend at the forest? R1: Yes. I usually stay in the forest, mostly, for a week. And one month if I have to stay longer. And I go once … well, I do sleep under a bed net or in a hammock net, but I still get malaria. R2: It depends. Sometimes, I stay there for one or two months. I: …Why is it so long? R2: Because the tractor may be broken, or we to come back and forth to the village when we run out of food. R3: Yes. I go to the forest … Like him, sometimes it also takes one month. If it doesn't take long, it will be half a month only. R4: I rarely go to the forest. I stay there for only four or five days. --- FGD in Teak Team village --- Who are the forest workers? Respondents described forest work as always communal. The composition of the groups who visited the forest together varied with the activity, distance and means of transport. Logging was an activity undertaken by groups of men, usually friends or relatives from the same village. Collecting malva nuts often drew mixed-gender groups, with husbands and wives sometimes working together. Groups were important when traveling by hand-tractor, to push the vehicle across the steep or muddy terrain. When in the forests, respondents often came across other groups engaged in similar activities. --- I: Do you see other groups of forest goers? R1: Yes. --- IDI in Kiribas Leu --- Sleeping arrangements Sleeping arrangements in the forests typically involved temporary camps, using individual hammocks and plastic tents or sheets to provide cover. Typically, groups would arrange their hammocks close to one another. The presence of water nearby influenced the choice of campsite location. Hammocks used by respondents usually incorporated a mosquito net. These were not necessarily insecticide-impregnated, referred to as "American" nets and bought from local markets. In contrast, respondents described that when in the village they used regularly the insecticide-treated bed nets that had been distributed by health centres and village malaria workers . I --- Malaria prevention and treatment --- Recognizing malaria infection Prior to the bout of malaria for which they were enrolled into the clinical trial, all respondents described previous experiences with malaria. For some, it was a regular occurrence: I: Have you got malaria before? R: Yes. I: How many times until now? R: Too many times that I can't remember…About 100 times. Six times a year or even twice a month. --- IDI in Lakay Village Although respondents explained that they were generally able to distinguish malaria from other febrile illnesses, there was some variability and vagueness in the symptoms that they associated with the disease: fever, chills, vomiting, headache, eye pain/dryness, bitter taste, exhaustion, lack of appetite or thirst, dizziness, hot flushes, generalized/muscle pain, paleness, malaise, fatigue and cold feet. Respondents cited different species of malaria-with vivax and falciparum mentionedbut made no distinction in terms of symptoms . --- I: What are the symptoms [of malaria]?… I: I would have a headache. I would feel pain in my bones, my arms and my feet. IDI in Kiribas Leu village I: Because each of you here has experienced malaria, I'd like to ask you about its symptoms. R: Sometimes, we might have dry eyes, a headache and shivering. Also, I get an unpleasant, bitter taste in my mouth. FGD in Lakay village These symptoms prompted respondents to seek diagnosis from the VMW or at a health centre or private clinic. At any of these locations, a rapid diagnostic test for malaria was viewed as necessary to make a formal diagnosis and for drugs to be prescribed. Respondents were generally familiar with RDTs and, when asked, most reported that they trusted the test result. When asked about the possibility of having malaria without symptoms, most were unconvinced and some confused by this idea, particularly when they had been asked about the symptoms associated with malaria infection. Three were open to the idea, though little explanation was offered. --- I: Earlier we discussed the symptoms of malaria, but do you think it's possible to be infected with malaria but not have any symptoms? There is no headache nor cold, yet could you have malaria? R1: I'm not sure about this. I: Do you understand the question? You know that you have the disease when you have headache and get a cold. What if you don't have these symptoms? Could you have malaria? R1: If there are no symptoms, I think it's not malaria. --- IDI in Lakay Village --- I: Do you think it's possible to get malaria but not have any symptoms? R: I usually have some symptoms. I: What I mean is you usually have high temperature or headache, which makes you do the blood test for malaria. But, now I don't have any symptoms and look healthy, do you think it's possible I am having malaria? R: I don't know. I think I know it when I'm not well. I: How? Do you mean when you have symptoms? R: Yes. I: Symptoms refer to when you have headache or dizziness. However, you don't have these symptoms. Could you be infected with malaria? R: No. IDI in Kiribas Leu village The respondents associated malaria with forest visits because of the presence of mosquitoes. They viewed malaria infection in their villages as possible, but less likely because there are fewer mosquitoes. Some were able to name specific places where malaria was an issue, generally associated with the environmental conditions. Malaria was described as one of the hazards of forest work that could not be avoided because of the economic imperative of this work. Respondents were aware of the limitations of their protective measures because they were bitten in the daytime, despite wearing long clothing. I: Can you think of the areas that is the most affected [by malaria]? R1: Nowadays, most people who get malaria are those who go to O Thmor Rolouy or O Dok Puet areas. Because a lot of them migrate there, so does malaria. I: Are they the areas of thick forests or mountains? R1: Both thick forests and mountains. --- FGD in Lakay Village --- Protecting oneself from malaria in the forest Respondents described using hammocks with integrated mosquito nets as a way of protecting themselves from malaria whilst in the forest. They acknowledged that sometimes-after an exhausting day of work-they fall asleep and forget to hang the net. Some of the hammock nets that were described as non-impregnated were bought from the local markets. They mentioned wearing long-sleeved clothes to prevent bites but complained about the heat and being bitten by mosquitoes even when wearing such garments. Some respondents described using repellents, mainly mosquito coils at night. Lighting a fire was occasionally seen as a way of preventing mosquito-bites. --- I: Do you know how to prevent mosquito bites? R: We should wear long sleeves and use bednets. I: Can you think of anything you didn't do that put you at risk of getting malaria? R: I got mosquito bites while I was working wearing a short sleeve shirt. IDI in Samor village --- It's very hot in the dry season, but we mostly use [the hammock] in the rainy season. [But] mosquitoes don't bite us during that time: usually, we get bitten whilst working FGD in Teak Team village Respondents did not mention taking drugs prophylactically . Moreover, their understanding of vaccination as a means to prevent disease in general was very poor: some mentioned a couple of diseases that are prevented by vaccinations, others were completely unaware of vaccination and many described not having ever been vaccinated. When asked about the possibility of taking medicines to prevent malaria, there were mixed responses: for some, they did not see them as necessary or did not like taking medication in general, whereas for others, the risk of malaria was such that taking medicines could be justified. For one respondent, this was on the assumption that the preventive drugs did not have any side effects. If the medicines could surely prevent malaria, I'll take them. On the contrary, I won't take the medicines if they are the same as the ones for treating malaria. I'm concerned they will affect my health. --- FGD in Teak Team village --- Treating malaria Respondents were familiar with the VMWs and described them as the first point-of-call if they suspected malaria infection. Two respondents however mentioned having encountered shortages of drugs that made them seek care at a health centre or private clinic. Most mentioned blood tests-from the VMW or the health centre-as the means to confirm an infection. Most had received a positive RDT diagnosis in the past and had taken anti-malarials. They viewed the RDT result as accurate, although one respondent had doubts after one instance of a negative RDT yet positive microscopy result . Respondents linked some complaints to the anti-malarials but reported that unwanted effects would not influence whether they took anti-malarials in the future to treat a bout of malaria. Two respondents described carrying RDTs, bought from the market or acquired from a VMW, into the forest in case any member of the group fell ill, as a means of determining whether they had to seek assistance. Four others described taking paracetamol on forest visits to treat the symptoms of minor febrile illnesses. During the focus group held in Lakay village, the possibility of taking antimalarials for treatment purposes was raised and respondents were keen to "be prepared in advance". I: Have you ever been tested and get a negative result when you were sick? R1: Yes. I: Yes? R1: Yes, one time I felt a bit dizzy and a bit cold, so I went to see the VMW. She told me that I didn't have malaria, but flu. She gave me medicines and I felt better. Sometimes I had gastroenteritis. I was given medicines and I recovered. I: So do you trust the RDT results to be accurate? R1: Yes. I: Did you bring it with you to the forest? R1: Yes. I: Who gave it to you? R1: I bought it at a market. --- I: How many did you bring with you each time you went to the forest? R1: two or three RDTs. IDI in Sean Moeur village --- Discussion The findings offer insight into practices and attitudes that put forest workers at risk of malaria infection. These are essential considerations for the design of prevention and control strategies for forest workers from culturally diverse villages in north-eastern Cambodia. Research on this topic-and the tailoring of interventions-is crucial because forest workers form a priority population for the elimination of malaria in the GMS [13]: they are at greater risk of sub-clinical infections [20] and their use of preventative interventions is often sub-optimal [17]. Infection outside villages brings a greater risk of P. vivax. Forest workers are also at risk of zoonotic malaria because they are more likely to come into contact with macaques and other monkey species, which carry predominantly simian Plasmodium species, such as P. cynomolgi and P. knowlesi, known to be capable of infecting humans [16]. The findings underline how-in the villages of Siem Pang, as in other rural settlements close to forests in the GMS [21]-forest work is part of everyday lives and remains an essential source of income. Respondents spent time in the forests undertaking a complex mix of activities, including logging and collecting other forest products, particularly malva nuts: logging was undertaken year-round by groups of men; whereas gathering forest products was more of a seasonal activity in which whole families could participate. These activities were not mutually exclusive and were sometimes combined with hunting and fishing. For some, forest work was their only source of income, whereas others combined it with farming, which impacted the timing and duration of forest visits. Daily routines in the forest varied, depending on the nature of activities, seasons and personal preference. Such heterogeneity complicates the tailoring of a malaria intervention package aimed at forest workers. There were notable similarities across the respondents, for example, sleeping in hammock-nets often not impregnated with insecticides. Most undertook their forest visits in groups and stayed in make-shift encampments with hammocks close to one another. They often encountered other groups in the forest, increasing the risk of malaria transmission. In general, respondents were concerned about malaria, and-as elsewhere in Cambodia and the wider GMS [22][23][24][25][26][27]-viewed the forest as an area of potential infection and sought to protect themselves-often sub-optimally-from mosquito-bites and malaria through wearing long-sleeved clothes, using mosquito repellents and/or lighting a fire. In terms of vector control measures, the tendency to use non-insecticide-impregnated hammock nets indicates at least one opportunity for improved prevention and control . Because forest workers can easily be neglected in villagebased approaches [22,23,30], the distribution of impregnated hammock nets would ideally be targeted toward members of forest-going groups or family members who could-if necessary-distribute nets to others who visit forests. In this area, distribution should not take place during the malva nut season when many community members are likely to be absent from villages. The willingness of forest workers to carry medicines with them to the forest to treat febrile illness [27,31] suggests some form of self-administration of an anti-malarial might be acceptable. Many respondents considered a set of symptoms as "malaria", with any underlying infection confirmed by RDT. They were unsure about the concept of asymptomatic malaria and few were ready to take the drugs in the absence of symptoms. Respondents were likely influenced by the messages from VMWs and other healthcare workers around the judicious use of antimalarials for symptomatic disease. This indicates potential challenges in achieving uptake of prophylaxis among this group and more targeted research is needed to assess the efficacy, acceptability and feasibility of this approach [3]. Respondents were also familiar with RDTs and placed the confidence in them, with some reportedly bringing RDTs with them to the forest. Respondents also described a readiness to self-treat. Therefore, distributing RDTs for self-testing alongside an ACT for self-treatment after a positive RDT result might appeal to forest workers. This could hasten appropriate treatment for clinical malaria, particularly given the distances that forest workers travel and the extended period they spend away from villages. A similar strategy has been piloted with international travellers who visit malaria endemic areas [32]. Although such a strategy might improve the management of clinical cases, it is unlikely to address malaria transmission maintained by asymptomatic infections and therefore is unlikely to contribute to the elimination of malaria in the GMS [33]. Studying forest work entails questions about and observations of activities that might place respondents in legal jeopardy: many of the forest activities are prohibited, particularly, as in the case in the study area, because they might take place in protected areas, such as national parks. Protecting the personal information of participants in any future research is therefore a priority. --- Strengths and limitations This is one of relatively few studies that have used qualitative research methods to specifically address malariarelated practices and attitudes of forest workers in the GMS [17]. Using a team of three trained researchers to collect data guarded against the undue influence of a single data collector on the findings. All interviews were conducted in Khmer, including those with respondents with other mother tongues. All respondents spoke Khmer in their daily lives and if unable to adequately express themselves during the interview, assistance was sought from another study team member who spoke the necessary local language and provided translated of specific terms. The data elicited from IDI respondents are limited by the recruitment approach: they all had participated in a clinical trial of malaria treatment in Siem Pang Health Centre. They had, therefore, sought treatment and this approach potentially excluded those unable or unwilling to seek care. Two additional focus groups involved participants recruited from the villages and therefore could have included those unable or unwilling to seek malaria treatment. The similarities between the responses offered by focus group participants from those from interview respondents indicates that this was unlikely to be a source of bias. The findings are drawn from reported data and might be subject to desirability bias, however, for practical reasons, it was not possible to accompany forest workers to undertake direct observations. All respondents were male. This reflects the fact that men are at highest risk for malaria because fewer women engage in forest work. The respondents were ethnically diverse and drawn from a range of villages. Respondents reported multiple bouts of malaria and, even though this group is at high risk, the number of self-reported malaria cases was surprisingly high. Reliable medical records were not available that could be used to link individual participants to proven malaria diagnoses . Although some of these bouts were reportedly confirmed with an RDT, it was not possible to systematically assess whether this was the case for each bout that the respondents described. --- Conclusions Forest work in Siem Pang District incorporates a diverse set of practices influenced by a range of factors. It is entangled with people's everyday lives and remains an essential source of income for some. Forest workers are concerned about malaria and try to prevent mosquito bites when in the forest. However, ITNs or hammock nets do not provide protection against outdoor day-time biting vectors. Offering RDT and ACT for self-administration appears acceptable but fails to address the impact of asymptomatic malaria on continued transmission. Respondents were unsure about taking anti-malarials in the absence of symptoms and research to establish the efficacy and feasibility of malaria prophylaxis for forestgoers in the GMS is urgently required. • fast, convenient online submission • thorough peer review by experienced researchers in your field • rapid publication on acceptance • support for research data, including large and complex data types • gold Open Access which fosters wider collaboration and increased citations maximum visibility for your research: over 100M website views per year --- • At BMC, research is always in progress. --- Learn more biomedcentral.com/submissions Ready to submit your research ? Choose BMC and benefit from: --- --- Supplementary information Supplementary information accompanies this paper at https ://doi. org/10.1186/s1293 6-019-3008-3. Additional file 1: Annex S1. --- Ethical approval and consent to participate The TACT-CV trial was registered on clinicaltrials.gov: NCT03355664 on the 28th of November 2017. The trial was approved by the Cambodian National Ethics Committee on Health Research reference 210, renewed 23rd February 2018, and Oxford Tropical Research Ethics Committee approval reference: 32-17, 30th November 2017. All respondents gave informed consent prior to participation. Written consent at the time of enrolment into a malaria treatment study, for those who were enrolled as malaria patients. For the interviews reported in this paper, verbal consent was obtained at the time of IDIs and from their peers during FGDs. In this research we adhered to the European Anthropological Association Code of Ethics. --- --- Competing interests The authors declare that they have no competing interests. ---

Background: Over the last 20 years, malaria incidence has decreased across the Greater Mekong Sub-region (GMS) and the emergence of artemisinin resistance has stimulated efforts to accelerate regional elimination. In the GMS, the malaria transmission is focused increasingly in forested zones. This article describes forest-going activities and examines forest workers' attitudes to and experiences of malaria prevention and control in north-eastern Cambodia.In Stung Treng Province, Cambodia, 19 in-depth interviews were conducted in villages with participants recently diagnosed with uncomplicated falciparum malaria who reported working in forests. Two focus group discussions with respondents' forest-working peers were held. Interviews and focus groups were audio-recorded transcribed, and translated for thematic analysis. Results: Forest work is an essential source of income for respondents. Many combine it with farming, which influences the timing and duration of forest visits. Forest activities include logging and collecting other forest products, particularly malva nuts. Men log year-round, whereas gathering forest products is seasonal and can involve entire families. Forest workers sleep chiefly in unimpregnated hammock nets in make-shift encampments. Respondents are concerned about symptomatic malaria, but unfamiliar with the concept of asymptomatic infection. They view the forest as an area of potential malaria infection and seek to protect themselves from mosquito bites through wearing long-sleeved clothes, using repellents, and lighting fires. Forest workers express a willingness to self-test and selfadminister anti-malarials. Conclusions: Forest workers' behaviour and perceptions of risk indicate that improvements are needed to current control measures. There is potential to: better target distribution of impregnated hammock nets; offer curative or presumptive treatment while in forests; and expand access to screening. Establishing the efficacy and feasibility of prophylaxis for forest workers in the GMS is a priority.

Introduction Once known as the 'Happy Isles', the small Western Pacific nation of the Solomon Islands experienced a number of episodes of internal conflict, transforming it into the 'Happy Isles in Crisis' . In May 2006, the Prime Minister, Manasseh Sogavare, presented the government's vision for the future. Among the policy proposals was the simple statement: 'government will strengthen mental health services and take measures to extend such services to vulnerable groups' . This research commenced in 2006 and explored systematically how policy decisions regarding mental health and wellbeing, over the previous 10 years, were made and incorporated into the national agenda. Mental disorders and psychosocial problems 1 present a significant global public health burden and are attracting increasing attention . They are stigmatizing, posing stress on the community and services; securing equitable and effective treatment and support is an ongoing human rights challenge . Attention has been devoted to mental health and wellbeing in the aftermath of violent conflict, reflecting awareness of increased rates of psychosocial problems and mental disorders accompanying such crises , together with a perception that additional support and services are required for those who have experienced 'trauma'. Intensified interest of donors and international nongovernmental organizations is often present, albeit typically for the short term . Powerful international actors influence the direction of policy and practice; their access to funds and analytic insights places them in a position of power relative to national government and local professionals . Thus, while international engagement and funding opens opportunities to rethink, reshape and redirect activities, there remains a risk that poorly designed policies and services may be introduced and may undermine local capacity, expertise, resilience and sustainability. Debate concerning good development practice in fragile states and in their health sectors is ongoing and intensifying . Approaches differ depending on whether one is dealing with a state which is weak, but committed to addressing the needs of its citizens, as in SI, or whether the state itself is repressive, violent and undermines human rights, thus making it a major part of the problem. --- Background: Solomon Islands and objectives of the project Located in the Pacific Ocean to the east of Papua New Guinea , SI comprise nearly 1000 islands covering a land area of 30 400 km 2 and a sea area of about 1.5 million km 2 . The 'backbone' comprises a double chain of six major islands: Choiseul, New Georgia, Isabel, Malaita, Makira and Guadalcanal, on which the capital, Honiara, is located. The population in 2007 was estimated at 567 800 . Over 83% of the population live in rural areas where subsistence agriculture, fishing and food gathering are the main sources of income . At independence from Britain in 1978, SI was a low-income, aid-dependent country with poor health and welfare indicators; it still has many of these features. Limited education, especially for rural communities and women, has been characteristic . In 2008, the Human Development Index placed SI 134 out of 179 countries . GDP per capita was $1586 in 2006 . The country is 96% Christian . Aid dependence is high, comprising 70.5% of Gross National Income in 2005, mostly bilateral, with Australia the largest donor . The recent global economic crisis may have exacerbated socio-economic and political vulnerabilities. The country experienced widespread armed conflict, known locally as the 'tensions ', from 1998', from to 2003', from ). Contributory factors included competition for limited land resources around Honiara and cultural differences between ethnic populations . After signing the Townsville Peace Agreement in October 2000, hostilities continued and escalated in southern Guadalcanal. The conflict is estimated to have resulted in 150-200 deaths, approximately 450 gun-related injuries, and more than 35 000 people becoming displaced . In 2003, Australia and a range of other countries were 'invited' by the SI government to establish the Regional Assistance Mission to the Solomon Islands to defuse the situation. RAMSI sought to strengthen governance, stabilize government finances and operations, revitalize the courts, rebuild the prison systems and strengthen the police service. According to the Australian Government, it also sought to build capacity and create the conditions necessary for a return to stability, peace and a functional, growing economy . In the health sector, Australian engagement was focused through the Health Institutional Strengthening Project . This research sought to examine how, and by whom, psychosocial and mental health needs were identified and responses determined in SI after these experiences of internal conflict. Underpinning the study was a concern to learn from national experiences and to help build more effective mental health policy and systems into the future. --- Methods --- Research approach This case study forms part of a larger project involving two national case studies , each spanning policy, service and community . The case study approach was chosen to facilitate examination of the influences on psychosocial and mental health policy given the diversity of the countries in culture, colonial history, level of development and experience of conflict. This paper covers the key policy-related questions studied in SI, which focused on understanding how, and by whom, psychosocial and mental health needs were identified and DECISION-MAKERS, DONORS AND DATA responses determined and who and what shaped the emerging psychosocial and mental health policies . --- Data sources and analysis Data were sourced through perusal of the relevant literature and interviews with key informants. Relevant published literature on mental health in SI and Pacific Island countries was sought, although there was a notable dearth. Unpublished documents concerning development, governance, policy, planning and health were also sourced and reviewed, including more specific Ministry of Health and other agency documentation. All these materials helped build contextual understanding, identifying the key actors and organizations, the processes through which policies and services were established, and key policy developments. Semi-structured interviews were conducted with 16 key informants from government, bilateral and multilateral institutions, local and international NGOs and the media. Informants were purposively selected for their ability to shed light on the processes of policy formulation and implementation. Interviews covered the key questions while allowing detailed exploration of issues to maximize insights from informants. Interviews were digitally recorded, transcribed, verified, and coded using NVivo 7. A national workshop with local and national stakeholders provided an opportunity for member-checking and assessment of the face validity of the analysis, and stimulated debate around the implications of the research for policy and practice. --- Results Analysis revealed two primary categories of findings: a sequential history of mental health service and policy development, and a detailed overview of the influences impacting on this development: socio-cultural issues; bureaucratic motivation; emerging evidence; political, security and economic concerns; and international aid. The discussion which follows draws on these issues to highlight the influences which helped place mental health policy on the agenda and assisted in driving it forward. --- History of mental health and psychosocial policy and services in the Solomon Islands Mental health and psychosocial services developed gradually over four decades. Formal mental health services in SI date back to 1950, when an asylum was established in Honiara. It was principally a place for custody of persons considered a danger to society or unable to care for themselves. Day-to-day care was provided by untrained staff, with weekly visits by a doctor. The Mental Treatment Ordinance was introduced ''. . .for the safety of society. . . rather than for the welfare of those affected. . .'' . In 1977, the Government built a 15-bed mental hospital in the grounds of Kilu'ufi Hospital in Auki, Malaita Province. In 1984, 12 new beds, funded by the British High Commission, were added to accommodate female patients. Like its predecessor, the facility lacked qualified mental health staff and adequate resources. The largely custodial care was provided by general nurses and nurse aides with medical support. In 1988, as part of a policy to make mental health services more accessible and acceptable, the MoH resumed responsibility for the facility from the provincial medical service, and it was renamed the National Psychiatric Unit . During the 1990s the country's first community mental health service was established in Honiara, together with attempts to recruit nursing staff as psychiatric co-ordinators in the provinces. In 1996, the Ministry started sending registered nurses for psychiatric training in Papua New Guinea . The number of qualified psychiatric nurses increased steadily, from three in --- Policy implementation -Service delivery --- Policy development What are the influences on policy in conflict and disaster? To what extent are issues such as gender, conflict, culture and human rights incorporated? Who shapes policy development and how? What is the link between policy and the services delivered to the community? What services currently exist; what are the gaps? How do services respond to issues regarding gender, conflict, culture and human rights? --- Solomon Islands East Timor --- Sharing experience across countries --- Community experience What has been the experience of the community? What are community perceptions of mental health services? What is the community's understanding of gender, culture, conflict and human rights? How important are these for psychosocial and mental health services? Figure 1 Research approach for entire project 1999 to 12 in 2006 . This coincided with increased efforts by the World Health Organization to put mental health 'on the map' . The first SI psychiatrist commenced duties in 2007, after studies in PNG and Australia . Since then, although the mental health workforce has expanded with the creation of additional nurse and nurse-aide posts, no further personnel have been sent for specialist training. There are currently no local psychologists, social workers or occupational therapists in the mental health workforce, aside from occasional overseas volunteers. Several hundred general nurses have undertaken in-service mental health training, but little is known about the application of such knowledge and skills. At different times the mental health services have been led by nurses and, for short periods, medical staff. In 2001 the lead position was titled 'Chief Nursing Officer, Psychiatry', highlighting the nursing background and leadership position envisaged. The Director at the time of study was an experienced and highly regarded psychiatric nurse with a Masters Degree in Nursing Administration. In 2005, a National Mental Health Strategy with a 5-year framework for action was adopted . Developed as part of the HISP, it was based on an integrated mental health model which spanned the continuum from mental health prevention and promotion to mental health care for those suffering from more serious mental disorders . Public social welfare services in SI date back to the mid-1960s, when increased urbanization brought concern for vulnerable groups. Services were initially focused on Honiara, provided by the City Council. Coverage was subsequently extended and services brought under the MoH. During the early 1970s, responsibility shifted between Health and Home Affairs, eventually coming back to Health, where it remains and is one of the smallest divisions with a total of 10 posts. The Social Welfare Division provides juvenile justice and family welfare services, and plays a limited strategic or policy-setting role. The social and welfare needs of the country are mainly met on an ad hoc basis through the churches and civil society organizations . None of the many NGOs in the SI focus specifically on mental health although a range of churches, NGOs and some UN agencies deliver some interventions, ranging from a focus on counselling to community development, women, youth and families. 3 Trauma support was provided to people in Guadalcanal and Malaita affected by the conflict ; most programmes were based and focused on Honiara although some had a provincial presence. --- Influences on mental health and psychosocial policy in and after conflict The key influences on mental health and psychosocial policy can be classified into six broad groups: socio-cultural issues; bureaucratic motivation; emerging evidence; political and security issues; economic concerns; and international aid. All had some relevance to the context in which mental health policy change occurred, its content, the processes employed and the range of actors and institutions involved . --- Socio-cultural influences Although SI society has followed traditional Melanesian cultural patterns, the research revealed socio-cultural factors reflecting the changing context due to processes of modernization and change. The 'wantok' system permeates social relations at family and community levels; extended family obligations have been prioritized over individual needs or responsibility to the workplace or government. We found a great diversity of island and language groups, with over 90 indigenous languages and dialects spoken in addition to SI Pijin and English . Traditional allegiances have remained strong: ''. . . Basically, although colonisation came, you still maintain those tribes. So we're living in two worlds if you like -yes, we are Box 1 Policy-related questions for overall research project How and by whom are psychosocial and mental health needs identified and responses determined? How has psychosocial and mental health policy developed? Who were the key actors seeking to influence policy? What were their different concerns? Through what means did they seek to exert their influence? What needs did the policy seek to address? How were those needs initially assessed? What gaps were left and why? What issues proved to be most contentious? Why? How were they resolved? What was the level of community input into the policy development process? Who influences the shape of psychosocial and mental health policy at national level? Where does psychosocial and mental health policy sit on the national government and national health agendas? What roles did the Ministry of Health, other ministries, donors, international NGOs, local NGOs and community members play in positioning the psychosocial and mental health agendas? What role did different donor agencies play in shaping these agendas? What were the values and principles underpinning the policy? What proposals for major initiatives were not taken forward, and why? What evidence and knowledge-base was drawn upon in this process? What human and other resources have been made available to take forward the policy? To what extent were these initiatives informed by sensitivity to gender, culture, conflict and human rights? Christians, we are Solomon Islanders, but I am Makira, you are Malaita.'' Some tribal groups are matriarchal, others patriarchal. Gender roles are clearly prescribed, as are the roles of young people. Women and men experienced and responded to the conflict and its sequelae differently . In the villages, young people with limited education and high expectations have had few opportunities for employment and participation in decision making, and many have moved to Honiara. Issues affecting youth, notably increasing levels of substance abuse and premarital sex, have posed challenges to government and a health sector anxious to prevent the spread of HIV/AIDS. With 40% of the population below the age of 15 years , and nearly the highest fertility rate in the Pacific , it is a ''frustratingly young society'' said a Solomon Islander from a local NGO . Youth disaffection is a major concern. Although traditional authority structures were already beginning to break down, assisted by the processes of urbanization and globalization, after the tensions; a lot of young people ''just followed their mind, whatever they wanted they could do'' . Emphasis was repeatedly placed upon the major transitions underway in society: ''. . . it's a transition period in the Solomon Islands between a very collective society, with adults still taking a very collective approach, to young people who are actually highly transitioning into an individualistic society and all the needs and all the demands that come with that that aren't being met.'' Patterns of help-seeking for both physical and mental disorders are shaped by traditional beliefs . The latter are often attributed to witchcraft, sorcery and the breaking of taboos . In recent years, there has been increasing recognition that health services are only one of the many resources consulted by people, and this is often done late: ''We're the last resort; if everything else fails they come to us'' . Socio-cultural issues influence both the composition of the policy-making group and the attitudes and values brought to the task of policy making. In 2006, all members of the national parliament and the great majority of senior public servants were men. The 'male dominated health system' reflected the male dominated society. In our study, the NGOs seemed more attuned to the needs of women and youth. Obligation to wantok is taken seriously by all Solomon Islanders at all levels of society. In other respects, however, indigenous community structures and practices, including traditional community mechanisms for coping with stress, have largely been overlooked or ignored by policy makers. The government has expressed an interest in strengthening the chiefly system, and the MoH has acknowledged traditional beliefs as having a major impact on utilization of services, particularly in the provinces . Civil society played a limited role in setting the agenda, but contributed substantially by working with community structures The Church, an important and widely respected institution in SI, was also not influential in driving policy, but played an important role in bolstering peripheral services. The Roman Catholic Archbishop of Honiara established the Trauma Support Program, now run by one of several NGOs funded by the Australian Agency for International Development . In 2000, ''he the ethnic tensions affected the people . . . and started looking for someone from outside to come and work with us in the Solomons . . . '' . Many senior bureaucrats were also senior church members. Both indigenous and expatriate informants stressed the importance of appreciating the impact of culture, including wantok, within development settings: '' . . . That's where some development processes miss out because they have not been able to understand the context, the localities, the struggles and the situation we find ourselves in . . . '' . --- The influence of bureaucratic motivation The total health budget was not large, equivalent to 5% of GDP , and many important issues competed for attention, such as malaria and maternal and child health. Key individuals within the MoH and its Executive played an important role in promoting attention to mental health and wellbeing. In particular, leadership and advocacy by the locally respected director of the mental health service, and his predecessors, facilitated movement from a custodial to a community-based model of care and rehabilitation. A policy-maker emphasized the role of this individual: ''[He] complains all the time about mental health being neglected in this country . . . It falls on [him]. If [he] is not active, nothing happens in mental health. If [he] is active, something is going to happen.'' The shift to a broader mental health orientation was reinforced by an MoH leader who embraced a population approach, as well as the donor-supported HISP initiative which opened space for population health interventions. Senior policy-makers and planners, a number of whom had completed postgraduate studies in public health, articulated a vision that incorporated the broader determinants of health , and provided leadership for a new agenda. This approach has been expressed as 'a search that draws together the optimum medical model, public health model and social wellbeing model in a new and comprehensive health and wellbeing paradigm for the Solomon Islands' . The 1999-2003 National Health Plan reflected a shift in focus away from hospitals towards primary care. Although limited attention was devoted to psychosocial and mental health issues, these resurfaced in relation to the ethnic tensions with the associated RAMSI intervention and health reform agenda, and support for mental health, social welfare and community-based rehabilitation was present. A clear agenda was identified, including better coordination and integration of services, improved links with NGOs and churches, and a greater focus on prevention. In the National Health Strategic Plan 2006-2010 the public health objective to '[s]trengthen social welfare, mental health and community-based rehabilitation and their community-focussed approaches' echoed broader government policy. Senior policy-makers continued to emphasise integration, including a multi-sectoral approach to mental health and psychosocial issues. A senior policy-maker told us: ''Our challenge now is . . . how best could we make sure that these issues and the policy could be equally recognised within the whole government?'' --- The influence of evidence and research In SI the burden to individuals, families and society associated with mental disorders has become increasingly apparent . A senior policy-maker remarked: ''Since 1998 I could see a trend emerging of mental health and psychosocial health problems increasing side to side''. Arguments for directing attention and resources to this area were based on an increase in the number of patients seen by the mental health services, including severe mental disorders, substance-related disorders and post . 2006). This shared commitment to valuing evidence provided an opportunity to reinforce attention to underlying and upstream issues: ''Under HISP [an externally funded project] we did a lot of national health reviews . . . a lot of evidence . . . collection of data and review to actually determine better what the health status is and where the problems are . . . '' . External assistance helped place information and data in the public domain, enabling debate. The reports prepared by foreign consultants for UNICEF A bureaucrat from the Ministry of Planning said: ''I think it's important to have data as evidence to drive our planning processes and then base our discussions on evidence rather than just talk without any verification or justification as to fact . . . All sectors must have a data mechanism in place to support the decision-making in policy, in planning, at programme level.'' A number of psychiatric and psychological sequelae were associated with this turmoil and social disruption, including untreated mental disorders, traumatic stress, widespread psychological distress and increased rates of substance misuse and suicide . From a health service perspective, the concern was even broader: ''the tension caused the collapse of the health system'' said a policy maker . Amongst the difficulties experienced had been disruptions in health worker payments, limitations in supplying medicines and closure of some services . The National Psychiatric Unit was closed for 9 months, while services at the 'Psychie Clinic', the community-based service in Honiara, were reduced . Transport of patients to Malaita was disrupted and people from other provinces were reluctant to go there. Concerns over access led to increased calls for decentralization of the mental health service . Socio-political and security challenges led to external intervention, notably through RAMSI. On the back of this security and peacekeeping initiative was ostensibly attention to broader issues of governance and development, albeit with significant limitations . Nevertheless, reflection during this period provided an opportunity to consider how best to address the determinants of mental health and prevent the recurrence of violence . An emphasis on young people and on rethinking the pattern of development investments surfaced, along with greater emphasis on equity. Disaffection with leaders of a new government established after elections in April 2006 led to riots in Honiara, with the Chinese commercial sector being especially targeted due to a perceived nexus with national politics. This renewed instability undermined confidence and rekindled anxieties among vulnerable groups, especially women and those affected by past violence. To some, it seemed that the earlier conflict had increased the sensitivity of people in Guadalcanal to corruption and wrong-doing, and their readiness to react with violence. Within the broader security context, several of our informants recognized the need to develop links across cultural and other divides, and to take these issues into account in planning services. ''Not all Solomon Islanders are enemies'' a Solomon Islander from a local NGO told us. Informants also recognized the potential of strategies that promote healthy lifestyles and ''a healthy mind'' in reducing the likelihood of future discrimination and conflict. Thus the context of security needs and reform reinforced efforts to address mental health issues with a focus on the entire population and a particular emphasis on young people. --- Economic influences The SI are among the poorest of the Pacific Islands . Ongoing economic challenges are significant and, combined with migration to urban areas, present new hurdles to psychosocial wellbeing and mental health: ''You have people coming together, moving together, mobility . . . I think that's one of the major causes of mental illness in this country-where people are. . . Economic drive can do all sorts of things to people. One of the things . . . is break down families and break down communities for the sake of moving forward. But when you talk about any development, how many times do we say what will this kind of development do, or how will this kind of development affect the mental state of people?'' Earlier gains in education and health were eroded by the conflict and subsequent social and economic collapse. Major economic activities, notably large oil plantations, gold mining, logging and some significant agricultural schemes in Guadalcanal, closed following the 1998-99 violence . While there has been some emphasis on young people and rural areas, projects have often not been appropriate or sustainable: ''We keep on going 'Oh, we're going to have rural approaches to young people' but they don't want to be pig farmers. Even if they did it wouldn't work, we've tried it before. . . We're 20 years behind the whole pigs and chickens approach to economic advancement, it doesn't work.'' Responding to social and economic changes presents a major challenge for the government, development agencies and donors. The government is ''very aware of the volatility of frustrated, disengaged and alienated communities'' . --- External influences and international aid Internal conflict led to foreign intervention. Together, RAMSI and HISP promoted enhanced security and the resumption of services. One HISP expatriate advisor explained: ''When RAMSI came in we actually had an avenue to get drugs and supplies out because they had the planes and the helicopters and the boats. Nothing else was working. . . RAMSI brought in a whole heap of control mechanisms . . . People, particularly nurses, felt safe to come to work.'' The same advisor described how, once the situation stabilized, evidence of the effects of conflict became apparent: ''For me it was very much displaced people and the mental health issues or the psychosocial issues that came with that . . . I would have seen four or five different major groups of displaced people . . . '' HISP played a valuable role. Some members ''had worked in conflict zones before and understood the impact, particularly at the population level, on populations that probably previously had pretty good mental health . . . also there were a couple of professionals on the team who had worked in mental health'' . Recognizing the need and opportunity, the HISP team worked to raise the profile of mental health and psychosocial issues within the broader health agenda. This complemented the voices, in national health conferences and other fora, of provincial health workers who identified the need to address psychosocial distress at community level, where it often presented in the context of family violence and substance abuse. The donor community concentrated on promoting a more stable macro-economic, security and development environment, but also sought to reinforce government leadership through identifying and responding to unmet need and enhancing reform opportunities. Technical advice and funds underpinned government initiatives. During and especially after the conflict, some of the donors worked with the SI government and the MoH to address psychosocial and mental health issues. Medium-term commitment provided opportunity for relationships of trust to be developed between expatriate and indigenous decision-makers. While the restoration of law and order was widely welcomed, in subsequent years the RAMSI intervention itself became a source of disaffection and stress; concerns were raised that not all parties had been brought to justice and aid and services were not being fairly distributed. The following exchange with a local development worker is illustrative: P11: ''I think the thing that happened is that people felt that the government is not giving enough attention to the provinces, and this belief that people in the hierarchy have been bought-off . . . '' Interviewer: Mistrust in the leadership . . . ? P11: ''Yes, lots of corruption and that sort of thing. People feel that a lot of aid is coming to the country but they are not seeing a difference in the communities.'' Thus, political tensions led to conflict and instability, which in turn were associated with psychological distress and social unrest. The RAMSI initiative led to enhanced security, new resources, new leadership and support to reform, including in health as manifest by the partnership between HISP and the MoH. Events in the SI coincided with increased attention to mental health issues globally, following publication of Mental Health: New Understanding, New Hope . In Honiara, World Mental Health Day 2001 was marked with a march by 200 people through the streets carrying the banner ''Stop the Exclusion -Dare to Care''. The Western Pacific Regional Strategy for Mental Health, launched in 2002, had two basic goals: to reduce the burden of mental ill-health and to improve quality of life by promoting mental health . In SI concern for the psychosocial needs of children and youth post-conflict led to a UNICEF situational analysis and strategic plan . Some of the external influences did not necessarily fit comfortably, locally: ''When we talk about rights . . . it certainly doesn't seem to fit culturally. That's been a poor approach in our understanding in how to communicate rights.'' The World Health Organization played a modest but supportive role over a 20-year period. International agencies and NGOs attracted additional funding and expertise and provided a base with which government could interact. For a short time, the Psychosocial Network, endorsed by UNICEF and supported by AusAID, provided an important forum for stakeholders, and supported training for counselling at community level. Policy makers found it difficult to confront foreign donors and advisors whose main concern may be short-term impact rather than sustainability. This reflects the broader asymmetry in power which often characterize donor-recipient country relationships. One expatriate advisor remarked: ''It requires confrontation, standing up and negotiation, which often happens in a roundabout way in this culture''. An SI policy maker agreed, suggesting that nationals may be disadvantaged in their relationships with international actors: ''We don't have the strength. We are a little bit naı ¨ve about many things and are easily exploitable. We are vulnerable and we give away ourselves too much. We smile too much to everybody. We're too kind. We're just vulnerable.'' --- Discussion This paper describes how mental health and psychosocial issues found their way onto the national health and development agenda in SI. Key policy drivers were the three 'p's often associated with agenda-setting: the problem, in this case the growing awareness and concern with mental health; the politics, here the instability and violence; and the policy, the ability to respond and improve systems and service provision. In taking these forward, they were underpinned by, and benefited from, support also from three 'd's: data in the various forms of evidence including that from research; decision-makers in relation to the bureaucrats and politicians who sought to address mental health; and donors who supported health reforms and enhanced systems, including those for mental health. Together these helped shape the policy agenda and progress it. Policy development was a process of incremental change, building upon a longstanding but limited concern with mental health and social welfare, along with strong advocacy from within the small mental health service. Armed conflict and ethnic tensions from 1998-2003 were followed by recognition, at least among health-related policy makers and service providers, of unmet mental health needs and psychosocial problems. Earlier advocacy by the World Health Organization around mental health may have played some part in underpinning these efforts. Additional support and impetus was garnered through the positioning of key health leaders, some of whom had been trained in population health. These individuals, embracing a population mental health approach and working with external support, drove the agenda. Contextual factors, notably further violence in 2006 and a growing youth population, along with emerging international and local evidence, intensified efforts. Dramatic changes in the political, economic and security environments focused policy attention on prior experiences of collective violence, the inadequacies of earlier development strategies and the need to engage with a wider range of development partners. Political fragility reinforced the need to address root causes, among which were unequal development, poor governance, and socio-cultural change. The latter was most apparent in relation to young people who have an increasingly tenuous link to traditional structures and expectations; greater exposure to alternate ways of living, behaving and relating; increased exposure to alcohol and drugs; inadequate access to education, training and employment opportunities; and increased migration to urban areas. Concurrently, the government recognized that 'right ways' of thinking and behaving require attention and support at community, provincial and national levels. National actors built their case around the community burden and the limited public sector response to psychosocial wellbeing and mental health issues. The conflict and its aftermath focused attention on the impact of collective violence: increased post-traumatic stress disorder, substance abuse and suicide; unmet care needs of those with serious mental illnesses; and the value of supporting community responses to psychosocial distress. More recent recognition of the political, economic, social and cultural determinants of health, and of development failures which, if not addressed, risked undermining both psychosocial wellbeing and national security, also played a part. Failure to address the psychosocial concerns of young people was seen by influential policy-makers as potentially explosive. The availability of international forces and donors funds, in large part associated with RAMSI, assisted in restoring stability, and also facilitated a review of governance and service delivery in sectors such as health. External engagement provided some space in which reflection could take place and new policies, strategies and responses could emerge. External agencies provided some support to building capacity and systems, providing extra resources through which attention to psychosocial wellbeing and mental health issues could occur. The bureaucracy within SI, probably as a result of increased professionalism, more skilled staff and possibly closer relationships with expatriate advisers and technical experts, identified the importance of various forms of evidence to help drive decision-making. This illustrates the value of efforts to promote evidence-informed policy . Better trained civil servants demanded information and data with which to help shape public policy decisions and guide the ministers, who otherwise were more influenced by patronage, wantok and other less 'objective' criteria. Not only has the agenda shifted, but so too has the content of policy . There has been a welcome shift in focus from custodial care and protection of individuals and the community to community-based services. Across the health sector, there has been greater awareness of the need to embed mental health within the primary health care framework, as well as to consider prevention and mental health promotion . Increasing recognition of community needs and perspectives will reinforce a trend to ensuring that policy and services are respectful and responsive to communities. The experience of SI echoes some of the observations from other settings. In Cambodia , Bosnia Herzegovina and Kosovo , the cessation of conflict led to an inflow of donor interest and resources, and opportunities to establish and or/reform the mental health system and associated policies. In both those settings, the drive was primarily from outside, from donors; local ownership, and ultimately sustainability of change, was limited. This differed from the SI experience where donor support and some of the things that may accompany it, such as better data and political momentum to support policy change, were present, but these bolstered an already established albeit under-resourced mental health programme. Donor engagement in an appropriate context may be supportive, as opposed to distorting, and may enhance the confidence and capability of local bureaucrats, policy makers and service providers to promote change. This appears to be the case in SI, where local ownership and commitment, from the small number of key people involved, were strong. --- Conclusion This case study presents insights into the emergence of mental health and psychosocial policy in a small island state recovering from conflict. The policy analysis undertaken reveals a nationally driven and internationally supported move towards mental health promotion and wellbeing, with a high-level commitment to socio-cultural relevance. Mental health was seen as important for a variety of reasons: it represented a potential problem, was politically sensitive, and policies existed to address it, thus illustrating a clear example of Kingdon's proposition that three 'p's-problem, politics, and policy-come together to drive agenda setting . These insights were underpinned and reinforced, in this particular setting, by three 'd's: a range of national decision-makers who were sensitive to the issues, donor personnel and resources which were supportive, and data which highlighted the need to revise the policy and extend services-decision makers, donors and data. None alone is likely to have mobilized the momentum to develop and drive the mental health agenda forward. The positioning of psychosocial and mental health issues is fragile, however, and remains dependent on demonstrating the links between poor mental health and issues of inadequate functioning, family and community instability and violence, and threats to national development. As in many developing country settings, providing an economic rationale for government and donor attention would help consolidate these issues on the national agenda. Over time, the ability to demonstrate that investments in psychosocial wellbeing and mental health lead to better health and social outcomes will, no doubt, be important.

Mental disorders and psychosocial problems are common, and present a significant public health burden globally. Increasingly, attention has been devoted to these issues in the aftermath of violent conflict. The Solomon Islands, a small Pacific island nation, has in recent years experienced periods of internal conflict. This article examines how policy decisions regarding mental health and wellbeing were incorporated into the national agenda in the years which followed. The study reveals the policy shifts, contextual influences and players responsible. The Solomon Islands' experience reflects incremental change, built upon longstanding but modest concern with mental health and social welfare issues, reinforced by advocacy from the small mental health team. Armed conflict and ethnic tensions from 1998 to 2003 promoted wider recognition of unmet mental health needs and psychosocial problems. Additional impetus was garnered through the positioning of key health leaders, some of whom were trained in public health. Working together, with an understanding of culture and politics, and drawing on external support, they drove the agenda. Contextual factors, notably further violence and the ongoing risk of instability, a growing youth population, and emerging international and local evidence, also played a part.

Introduction Millions of children globally have been survivors of child sexual abuse -according to the World Health Organization's 2022 "World report on violence and health", the lifetime prevalence of CSA is 20% for women and 8% for men [1]. CSA survivors are at a higher risk of experiencing mental health challenges following the abuse. Such challenges include the development of posttraumatic stress disorder , suicidal ideation and attempts, increased healthcare utilization, and engaging in health-risk behaviours [2,3]. Accessing effective and specialized treatment for the unique needs of CSA survivors is important. However, many cases of CSA go undisclosed and therefore untreated. A reluctance to disclose can arise from a multitude of reasons ranging from feelings of guilt or a belief they will not be believed due to fear of stigma and negative cultural outlooks [4,5]. Caregivers play an essential role in facilitating care for CSA survivors and previous studies have shown multiple levels of barriers to accessing mental health services [6]. For CSA survivors, access to therapy is challenging due to stigma . Trust is particularly important in engaging CSA survivors and their families and protection of anonymity of children and caregivers is important [8,9], in alignment with a trauma-informed approach [10]. We were interested in getting feedback about the Little Warriors treatment facility for CSA survivors. To address this, we adopted a novel engagement approach using a hybrid webinar/focus group strategy with video conferencing technology . By involving two stakeholder groups , as suggested by previous systematic reviews, we developed an efficient and ethical way to engage caregivers of CSA survivors and generate value for stakeholders in an anonymous question and answer format [13]. The conceptualization of this approach arose during discussions around the challenges in engaging with vulnerable populations, such as CSA survivors, and COVID-19 public health measures. Our research team first considered piloting a hybrid webinar/focus group approach to stimulate engagement. This option was deemed attractive as it may offer value on caregivers in relation to clinical program information. Given a voluntary choice to participate in a hybrid webinar/focus group, this approach was considered as it also facilitated engagement as opposed to being coercive. The hybrid approach, which combines webinar and focus group elements, utilizes video conferencing technology, making it convenient and accessible for caregivers to participate from their own homes or locations of their choice. This eliminates the need for physical travel and reduces the barriers associated with in-person meetings. It also allows participants to join the sessions using anonymous profiles, protecting their identity and providing a sense of safety. This anonymity can encourage caregivers to share their experiences and opinions more openly, as they may feel more comfortable discussing sensitive or stigmatized issues. A similar approach was used with university students [14], but it has not been investigated in clinical populations. Deeb-Sossa and colleagues [14] aimed to diversify the college admissions applicant pool at the University of California, Davis. Their results suggest use of a virtual webinar format introduces students as well as their families to campus life helps minority groups making enrollment decisions, especially during COVID-19. When implementing this type of approach, it is important to consider some general statistics around webinar attendance in the general public domain. In accord with several public domain sources, a recent report of business webinar statistics indicates that typically an average of 260 individuals registers for a webinar but only 40-50% people may attend, and 78% of business to consumer webinars have � 50 people in attendance [15]. Given the vulnerable nature of our CSA community and our experience of consulting with treatment facility stakeholders, we considered a priori that an attendance of � 15% of registrants attending would be a successful outcome. With this goal in mind, we hypothesized that a hybrid webinar/focus group approach will be an effective engagement strategy to obtain information regarding therapy access, for the highly sensitive population of caregivers of CSA survivors. --- Materials and methods --- Approach We hosted two hybrid webinar/focus groups to increase participant engagement in a workshop style format using the webinar function on Zoom . This webinar function allows use of the Q&A function to respond anonymously to the moderators. The option to "up-vote" popular questions was considered useful for keeping track of questions during sessions. During the one hour hybrid webinar/focus group session, the main moderator described research and programming at Little Warriors for about 10-15 minutes. After this, the moderator then posed five open-ended prompts to stimulate audience feedback for the remainder of the one hour session. The main purpose was to investigate how a multimodal treatment program was received for caregivers of CSA survivors. Feedback discussion was facilitated by the main moderator and two staff members, and the prompts were partially adapted from the Alberta Quality Matrix for Health [16]. From a trauma-informed perspective, this supported a 'warm-handoff' between someone more familiar to the caregiver and the researcher. Prompts were comprised of: 1. What has been working for you and your child? 2. What hasn't been working for you and your child? 3. What can we do to improve? 4. How was the intake process for you? Easy? Difficult? 5. What did you/your child find most helpful in the time at Little Warriors? --- Study context Little Warriors is a novel intensive multimodal not-for-profit treatment program for children and adolescents with a CSA history [12]. The Little Warriors Be Brave Ranch facility is "camp-like" in order to create a fun and recreational environment for activities. BBR programming includes treatment rounds for cohorts aged 8-12 years old as well as 13-16 year old adolescents. Each individual cohort consists of approximately 6-12 children. --- Data collection This study was approved by the University of Alberta Human Research Ethics Committee . In fall of 2021, all 89 caregivers were invited by Little Warriors via email to participate in a hybrid webinar/focus group that included an open Q&A period. We took everybody we could with an inclusive list of caregivers who were on record with children in this program, thereby representing 89 caregivers and minimizing recruitment bias. For the present study, all caregivers that had a child that was either in or had completed treatment were included. Caregivers were excluded if their child had not participated in the Little Warriors treatment programming. Implied Consent was obtained at the beginning of the hybrid webinar/focus group session, meaning those who participate are indicating they are comfortable with having their responses recorded and anonymously analyzed. For the caregiver data obtained from the hybrid webinar-focus group, we originally proposed obtaining written consent from caregivers prior to the study. However, we found that anonymity was better maintained by the setup of our webinar where individuals were invited to attend. The webinar was a safe environment because personal data was never at risk. Due to the sensitive nature of the population, implied consent was deemed the most efficient method to get information and the ethics committee was satisfied with our proposal. We also did not require follow up so implied consent was adequate. Furthermore, since this data collection did not involve the collection or use of health information, the Research Ethics Committee deemed that there was little risk to participants and that implied consent was both practical and appropriate and better protected the confidentiality of participants-confidential responses from the question-and-answer session were analyzed for attitudes/opinions of the parents/guardians. Participants were also provided with information prior to the group activity in order to make a fully informed decision regarding their contributions. During the hybrid webinar/focus group, anonymized responses of caregiver attitudes and opinions were captured using the Q&A function on Zoom webinars, so anonymity of participants was protected. All moderators present signed a confidentiality agreement through the University of Alberta's Human Research Ethics Board. In order to maintain a continuous flow in conversation throughout, the moderator posed questions to the staff for their opinions during times when caregiver responses were not being entertained. The sessions were conducted in English, via Zoom, and lasted approximately one hour. Two sessions were held in November 2021 and both sessions were recorded. Encrypted Zoom links were sent out by Little Warriors and recordings were stored in a secured online file only accessible by research team members. As a note, three moderators were actively involved in the hybrid webinar/focus group discussions, as they facilitated the conversation and asked questions . In this sense, we qualify them as being participants in the study. As a result, their inclusion in the count of participants reflects their contribution to the data collection process. Additionally, we want to highlight that moderators were not passive observers, but rather played a critical role in ensuring the success of our novel approach by engaging participants and promoting a rich/continuous discussion throughout the session. Moderators presented information according to standard script and they brought questions, raised by participants, into the conversation in a nondirective way-participant feedback drove the discussion. The facilitators had no vested interested in the content arising from participants and their job was to be sensitive and receptive. --- Data analysis We used qualitative thematic analysis to better understand the attitudes/opinions of caregivers with children enrolled in treatment at Little Warriors [17]. The recorded sessions were transcribed , and two independent coders thematically analyzed the transcripts using Braun and Clarke's methodology [18]. Qualitative data analysis was used to identify, analyze, and summarize themes in detail. Initial coding of transcripts was completed by two independent team members using an inductive approach. This allowed for inter-rater reliability and confirmability [19,20]. Steps taken to complete the analysis included the following. First, the two independent team members thoroughly read the transcripts multiple times to immerse themselves in the data. This allowed the team members to gain a perspective of the data without even beginning to code. Once completed, the two independent reviews then began the preliminary coding process. This consisted of the two members creating a Word document that contained a table with the transcript in one column and the open invivo codes in a secondary column. Inductive coding was used at this point in order to ensure that participant voices were heard without the influence of the study question. Second, once created, these inductive open codes were combined and the two team members began searching for preliminary themes a larger team was engaged in an additional round of analysis on deductive coding guided by the study objectives. These deductive codes were then combined with the inductive codes, and comparisons occurred if the deductive codes could be matched with the preliminary themes established for the inductive codes which did occur. Third, the themes were reviewed in light of the original data to determine if the interpretation seemed to capture the essence of participants' words, phrases, and potential meanings. Regular meetings involved discussion, code verification, resolution of discrepancies, and confirmation of final themes with research team members who were bound by confidentiality. An audit trail of memos and discussion minutes was used to verify decisions about themes and to maintain credibility as well as rigor throughout the thematic analysis [21]. Standard qualitative research reporting requirements were followed [22]. --- Results --- Quantitative descriptive analysis 89 caregivers were invited and 11 attended the webinar, which represents 55% of the 20 caregivers who registered. A total of 16 unique participants, including caregivers, clinicians and moderators, contributed to the data in the present thematic analysis . Hybrid webinar/focus groups were conducted on November 22, 2021 and November 25, 2021 . Two caregivers intended to participate in Session 2 but could not join due to limited time or technical difficulties. A research team member followed up via email twice to provide additional opportunities for feedback, but no responses were received. This preliminary study is part of an ongoing program evaluation, so data saturation will be determined in future qualitative evaluation studies [23]. --- Thematic analysis The hybrid webinar/focus groups conducted yielded several major themes. Themes include: Challenges of starting and maintaining treatment, Therapeutic benefits of specialized treatment, and Barriers and facilitators of treatment. These major themes and related sub-themes are summarized in Table 2 and are presented with greater detail in the following sections. --- Moral injury wounds addressed Something about moral injury/PTSD-related factors addressed in treatment "But what really worked was strategies he was taught at the ranch, they totally took the shame out of his pain. As he moved forward, this was one of the most important things." . "And it [incident of child sexual abuse] doesn't define them." . --- Trauma informed staff Something about staff being emotionally attuned, present, skilled, and empathic 1. Challenges of starting and maintaining treatment. Caregivers and staff identified the challenge of keeping the children in treatment rounds until completion. These challenges are not surprising given the intensity of the childrens' trauma histories and the substantial commitment on the part of the children to go to an unfamiliar place for several weeks away from family. Sub-themes include: Emotional burden of intake day and Staying in treatment. "[W]e' 1.1 Emotional burden of intake day. Intake day was unanimously identified as an emotional day for both caregivers and staff. For staff, they have gone through the intake process for many families and identified common themes of the experience being difficult emotionally. For caregivers, there seems to be an emotional toll that is accrued during intake day. Caregivers pointed out the difficulty in saying goodbye to their child at the facility. However, caregivers also mentioned that the burden of intake day was well worth it, given how it helped their families and the fact that the interview process was not rushed. One caregiver was relieved that there was in fact treatment available for children with a history of CSA. The fact that this multimodal treatment programming exists seems to offer families hope that their child can work toward recovery even after severe early life trauma. 1.2 Staying in treatment. Given the high degree of heterogeneity in the Little Warriors' population, some families found that maintaining treatment was hard. These factors can be --- Challenges of maintaining selfcare Something about self-care and associated financial barriers "We have kids that think self care can only be bubble baths. And so teaching them like no, like, there's things that you can do outside of that for self care and getting them to internally reflect and learn how to take care of themselves, really, without relying on outside things." (Staff, W1 internal such as homesickness and also external such as location. Living away from their families in a new environment seems to be a difficulty that many children face during the first few weeks of treatment. However, challenges may also reflect mental health difficulties. Another factor included school, where missing out on substantial schooling means falling behind peers in terms of grade level as well as emotional maturity. 2. Therapeutic benefits of specialized treatment. Aside from the challenges reported by caregivers and staff, there were several therapeutic benefits observed. In this theme, both caregivers and staff identified specific areas that provided therapeutic benefits for children at Little Warriors. Little Warriors splits children into small cohorts and uses a multimodal approach with several different types of therapies used throughout treatment. Given the nature of this multimodal programming, the benefits described make sense, as children have the space to gravitate toward specific treatments that they find most helpful. Sub-themes include: Not feeling alone, Feeling safe and supported, Moral injury wounds addressed, and Trauma informed staff. 2.1 Not feeling alone. Child sexual abuse can be a severely isolating experience not only for children but also for families. The high cost of feeling isolated is associated with a response to trauma, where children believe that they are the only one affected by abuse. As children come to Little Warriors and start interacting with their cohort, they realize that they are in fact not alone. It seems that the cohort approach helps to mitigate some of the harmful effects of CSA. 2.2 Feeling safe and supported. One key factor that both groups identified to achieving optimal treatment outcomes is feeling safe. Clinicians emphasize giving ample time to adjust and build rapport in efforts to support children. Having the resources to create a safe environment where children can gradually open up emotionally appears important, as the treatment commitment can be frightening and overwhelming to families. Ensuring caregivers have space to ask questions is important. Staff ensure that families are fully informed of the supportive environment by adapting tours to the COVID-19 virtual environment. Programming also plays a role in facilitating psychoeducation. Psychoeducation then allows children to bring these skills back home and to continue their relationship with their caregivers post-treatment. The use of small cohorts was also instrumental for creating a sense of safety and comfort for children. --- Moral injury wounds addressed. Children with a history of multiple and prolonged incidents of abuse have enormous stress in their lives and coming to an unknown treatment facility with strangers can be an added burden. Thus, the road to recovery is a gradual process. One topic that arose across caregivers was the devastating impact of shame associated with CSA that was adequately addressed in treatment. It seems that the multimodal treatment approach was effective in addressing issues related to the construct of moral injury in terms of shame specifically. The careful attention to addressing psychological wounds at Little Warriors helps children to start to build resilience. 2.4 Trauma informed staff. The staff at Little Warriors are trauma informed and they have specialized training to manage behavioral and/or emotional crises. The staff and value their own mental health as well which serves as great models for the children they interact with on-site. It seems that having rest/compassion fatigue weeks with no treatment programming is important to maintaining the wellbeing of staff and to avoid burnout. One of the key principles of trauma-informed care is to foster empowerment in patients, which in turn sets the stage for establishing trustworthiness. 3. Barriers and facilitators of treatment. In light of the therapeutic benefits mentioned above, caregivers and staff reported examples of factors that hindered as well as facilitated treatment progress. In this theme, both caregivers and staff identified specific factors that got in the way of the treatment for their child as well as factors that need to be scaled up in the future. Factors identified in this theme related to the children's wellbeing, resources at Little Warriors, and staff. Sub-themes include: Future areas to scale up, Residual psychological wounds, and Challenges of maintaining selfcare. 3.1 Future areas to scale up. There were some areas that caregivers identified as needing scaling up. In terms of resources, this may be addressed by re-allocating the existing resources to better support families post-treatment, or potentially adding additional resources. Ensuring that schools have counselors can be of benefit to children as they make the transition back to school post-therapy. Specifically related to COVID-19, there were some programs that were postponed due to public health measures, but future directions could include ways to adapt to the virtual environment. Also, it seems that cultural activities are valued and received well by families and caregivers at Little Warriors. 3.2 Residual psychological wounds. Due to the severity of trauma in CSA, there can often be residual psychological wounds that factor into how well a child progresses. It seems that treatment progress is not linear, and this is not surprising given the severity and nature of trauma these children experience. Some children may have persisting difficulties with peers. Others want to leave treatment early to go back home. In light of these interpersonal challenges, sometimes persevering through them with the support of trauma-informed staff and supportive family is the best course of action to facilitate recovery. 3.3 Challenges of maintaining self-care. Staff spend time educating what self-care is to children by clearing up misconceptions-staff also model self-care themselves. Staff self-care skills play an important role in protecting against things such as burnout and vicarious trauma. Moreover, through educating and modelling, staff communicate to children and families the non-negotiable nature of maintaining self-care as it relates to emotional regulation and wellness in general. --- Discussion This study demonstrated some of the unique challenges that caregivers of CSA survivors face in relation to therapy access. Due to the difficulties of eliciting feedback from vulnerable populations, this study adopted a unique hybrid webinar/focus group approach to engage a sample of caregivers of CSA survivors at Little Warriors. We found that piloting this novel approach was an ethical and efficient way to stimulate engagement in a highly sensitive clinical population that has been historically difficult to engage with at our facility. The use of this hybrid webinar/ focus group strategy may be applicable to other contexts outside of health research due to its flexible and efficient infrastructure using video conferencing technology. Importantly, this approach is also adaptable to the COVID-19 virtual environment and has shown encouraging results in a sensitive population for the present study. At the highest level of scale-up, this approach could be used in a similar fashion to consensus conferences [24]. We discuss barriers and facilitators that arose from our thematic analysis and also several advantages of our hybrid webinar/focus group approach below. Findings may not be generalizable to all caregivers of CSA survivors though since this study was conducted with a sample from a specific facility. One of the core principles of trauma-informed care is to build a strong therapeutic alliance with the client [25]. Opportunities to start developing rapport begin with intake day when caregivers hand off their children to facility staff. Both caregivers and staff reported that intake day was emotionally burdensome in our thematic analysis. Given the theme reported in, "Emotional burden of intake day", it is important to note that avoidance, by both the caregiver and child, has been previously found to predict child outcomes as well as treatment drop-out [26,27]. In order to bolster a therapeutic alliance in a trauma-informed approach and to improve treatment retention, clinicians can play a role in supporting caregivers to actively engage during the intake process. This includes making sure caregivers are well informed as staff discuss and set expectations for therapy, outlining treatment topics that will be covered during the course of care [28]. Staff can also ensure adequate time to address caregiver concerns and questions early on in treatment. Finally, there should be resources available for emotional support if caregivers decline treatment in the form of psychoeducation. Barriers to engagement/recruitment previously found in the literature relate to the time commitment and value for participants [13]. The present hybrid webinar/focus group approach was able to address this barrier, in a cost-effective and efficient manner, by having a Q&A session where caregivers could obtain any clinical programming information they were looking for directly from staff at Little Warriors in 30-60 minute sessions. Caregivers also learned about the value of future research studies planned at Little Warriors, so that they have the option to participate in the ongoing program evaluation for children and adolescents' recovery. We believe that the success in these responses was a consequence of creating a safe environment wherein both stakeholders were incorporated and having a continuous conversation sustained throughout the whole session [29]. Sensitive populations can be especially challenging to engage with due to stigma and the need for establishing trust [7]-populations such as CSA survivors and their families are one example. For health research in general, obtaining information about patient identified priorities and areas of improvement are essential for improving treatment outcomes and supporting families in their recovery [30]. However, it can be difficult to obtain sensitive information especially in a traditional in-person focus group setting, since disclosure could result in feeling stigmatized [7]. Participants may recognize each other in a traditional in-person focus group setting which may reduce the quality of content shared, especially given the sensitive nature of topics discussed. In terms of individual interviews, participants could feel less inclined to share information in a one-on-one setting if the interviewer is of another gender or cultural background, for example [31], potentially due toa power dynamic affects the quality of information shared. The uniqueness of the present hybrid webinar/focus group format allows for caregivers to give anonymized feedback by typing in their responses in a Q&A chat box, relating to key areas of program improvement and implementation. We carefully considered options for interacting with this vulnerable community and after considerable discussion from an ethical perspective, we decided that maximizing privacy and minimizing contact was the optimal approach to make the context safe and to reduce the possibility of increasing any trauma experiences. This overriding concern for the wellbeing of participants made the anonymized webinar approach a definite choice of advantage-this was also appreciated by the ethics committee. This anonymized approach to engagement is distinct amongst traditional methods of data collection [32]. Given the unique challenges of working in a highly sensitive population as well as the elevated number of no-shows reported in previous literature on virtual events versus in-person [33], we still generated a sample within the recommended focus group size in the COVID-19 virtual environment [34,35]. Interestingly, the clinical director of Little Warriors noted that some historically difficult-to-engage caregivers ended up participating in the present hybrid webinar/focus groups. We suspect that this is a result of using anonymized responses in a video conferencing format, which facilitated open communication about sensitive information. Furthermore, protecting the anonymity of participants has been recognized as a factor in establishing trust, which is crucial when engaging with sensitive populations [8,9]. Several limitations to this novel recruitment strategy approach include: first, the hybrid webinar/focus group approach has not been evaluated in other contexts, but is flexible enough to be useful with other sensitive/vulnerable populations. Anonymous responses captured through video conferencing allowed participants to identify patient-identified priorities and information regarding treatment in private. Second, content discussed throughout the hybrid webinar/focus groups could be potentially triggering to participants. The University Ethics Board accepted our rationale that obtaining implied consent at the beginning of the session represented a safety measure for participants in addition to provision of contact information for research team members and Little Warriors to direct participants to appropriate care pathways, if needed. Third, access issues posed a limitation specifically for participants who missed the hybrid webinar/focus group. We did our best to ensure two different evening times were scheduled for sessions to allow for caregivers to attend after work hours. Additionally, we provided information about downloading and using the video conferencing platform-a technical moderator was also on call to troubleshoot any user difficulties. Despite these measures, two caregivers who indicated interest in attending the hybrid webinar/focus group session were unable to join due to availability [i.e., scheduling conflict arose unexpectedly] or technical difficulties [i.e., video conferencing platform was not working for the participant]. One can always expect subject loss in internet-based environments because quality of access to internet can vary. In studies of this kind, it may be possible to offer internet access at a specific site in the future to offset technical difficulties . Fourth, overall response rate was low compared to the number of caregivers originally invited, but 55% of registrants attended the seminar [far in excess of our expectations for a successful outcome and around the level of registrant attendance for general business webinars [15]]. Those participants who attended may have differed from those who did not, which presents a possibility of a self-selection bias and reduction in generalizability. --- Conclusion Our thematic analysis shows that clinical staff can collaborate with families to actively foster a strong therapeutic alliance. Caregivers identified that resources could be better allocated to support families post-treatment. This hybrid webinar/focus group approach efficiently and ethically engaged caregivers of CSA survivors with the benefit of informational value. Invitations were sent and individuals voluntarily registered without follow-up calls or the need for individual person to person interaction. We acknowledge that our study focused recruitment on a specific caregiver population with children enrolled at Little Warriors. Little Warriors research team members confirmed that caregiver participation has always been very low at Little Warriors. Despite this history, we gained a rich qualitative dataset from 11 different caregivers using this approach, within the COVID-19 context. Our sample was also within recommended focus group sizes of six to twelve, so these encouraging preliminary results call for further evaluation [35]. This approach also has an added benefit in that it is completely virtual and adaptable to the COVID-19 virtual environment. Although this pilot study and approach was successful in obtaining feedback at our facility , further efforts to replicate this preliminary approach in other populations outside our clinical context are recommended. --- S2 File. Full anonymized transcript of webinar session 2. --- All relevant data are within the paper and its Supporting Information files. --- Supporting information --- S1 File. Full anonymized transcript of webinar session 1. ---

Difficulties in access to therapy were highlighted by COVID-19 measures restricting in-person gatherings. Additional challenges arise when focusing on caregivers of child sexual abuse (CSA) survivors in particular, which are a population that has been historically difficult to engage with due to issues of stigma and confidentiality.To present preliminary qualitative results from caregivers of CSA survivors.This study was conducted with caregivers of CSA survivors. Two hybrid webinar/focus groups were conducted using a video conferencing platform in fall of 2021 with two groups of stakeholders (11 caregivers and 5 moderators/clinical staff at Little Warriors, an intensive episodic treatment facility). Sessions were recorded, transcribed, and thematically-analyzed using standard qualitative methodology.A total of 11 caregivers contributed to the data. Themes include: (1) Challenges of starting and maintaining treatment (i.e., emotional impact of intake day, challenges of enrolling), (2) Therapeutic benefits of specialized treatment (i.e., feeling safe and supported and the importance of trauma-informed care), and (3) Barriers and facilitators of treatment (i.e., avenues to scale-up and self-care).The importance of a strong therapeutic alliance was highlighted by both caregivers/clinical staff and further support is needed for families post-treatment. The present hybrid webinar/ focus group also achieved engagement goals in a population that is typically difficult to

. For example, a special section in the June 2010 issue of Alcoholism: Clinical and Experimental Research discussed advances and future prospects in alcohol biomarker research in clinical and applied settings . The examination of biological data can be used to improve understanding of the biological mechanisms underlying substance use and abuse . Moreover, biomarkers have been presented in the substance use literature as a way of validating self-report measures and improving estimates of substance use . As Peterson points out, research on biomarkers linked to alcohol consumption has the potential to improve clinical assessment and treatment, and also stands to improve precision of measurement in research, going beyond the standard self-report measures that typically require participants to recall the number of drinks consumed over a specific time period. Advances in molecular techniques and increased recognition of the interactions between biological and social factors have led to the collection of both forms of data in studies of population health . Given declines in study participation and the growing recognition that both social and biological data are needed to better understand substance use and addictions, innovative sampling and data collection strategies are required that maximize researchers' ability to obtain both types of data from representative population samples. In the present article we describe a "random walk" door-todoor recruitment strategy for randomly selecting a community sample for participation in a study on mental health, substance use, addiction, and violence problems. As part of a larger multidisciplinary program of research, we collected self-reported health information as well as biological specimens to improve understanding of the independent and interactive effects of biological and social factors on MSAV problems . The overarching goal of the present study was to develop a methodology for randomly selecting a general population sample and collecting both biological and social data as part of a community survey. --- Why new, innovative approaches to sampling are needed in health surveys Researchers relying on traditional survey methods, such as telephone and mail approaches, have increasingly struggled to generate adequate samples for epidemiological research purposes . Most developed countries still rely heavily on the telephone survey method to collect population health information, and the growing use of mobile phones, answering machines, voice mail, caller ID, and "do not call" lists are contributing to declines in response rates . Telephone surveys relying on random digit dialing may be particularly prone to noncoverage bias if only landlines are included in the sampling frame, since individuals who exclusively use mobile phones will be missed . Young adults, for instance, tend to predominantly utilize mobile phones , rendering this group particularly challenging to reach in telephone surveys relying on landline extensions. Likewise, internet surveys do not seem to hold much promise for augmenting response rates on population surveys ; this is especially true when researchers are interested in collecting biological data. For example, Avendano, Mackenbach, & Scherpenzeel evaluated the feasibility of collecting biomarkers through an internet survey and found response rates in the order of 15.0% to 26.5% . A household sampling procedure involving door-to-door recruitment and face-to-face contact may facilitate recruitment of survey participants by eliminating the need for accurate telephone listings and avoiding the noncoverage pitfall associated with RDD. In principle, a door-to-door recruitment approach involving in-person contact can allow for more convincing explanations of the importance of the research and assurances of confidentiality, both of which are particularly important for surveys about sensitive topics such as personal health . For example, in their recruitment of inner-city African-American women to a cancer screening intervention program, Blumenthal, Sung, Coates, Williams, and Liff found that in-person recruitment was superior to telephone recruitment. Door-to-door recruitment approaches for epidemiological studies on substance use stand to be useful in diverse settings, including both developed and developing countries. Conducting high-quality surveys in developing countries is particularly challenging, as limitations on technology and resources impede the implementation of many advanced survey methodologies . Telephone and web-based surveys are usually impractical in developing countries because many people do not have a telephone or access to a computer. Many regions lack the documented population/household information needed for generating sampling frames , while in other areas, conflict or instability complicate survey implementation . Door-to-door recruitment may also have particular applicability to epidemiological studies involving the collection of biological data. With a few exceptions , participation rates in epidemiologic surveys that include a biological component are not well known, partly due to poor reporting practices in the epidemiological literature ------IJADR 2 ------. Moreover, little is known about how response rates associated with biological sample provision compare to other survey components. Few studies have combined the collection of both biological and social data on a large scale, and little research has been conducted on the most effective methods of collecting biological specimens as part of household surveys. Overall, researchers suggest that better field methods for collecting biological data in epidemiological surveys are needed and argue the need to report response rates separately for biological and non-biological components . --- The "Random Walk" Method The random walk approach is a simplified cluster sampling method developed by the World Health Organization and originally implemented in the Expanded Programme on Immunization . In this approach, a population is divided into a specified number of geographic "clusters" of a known or estimable population size . Clusters are randomly selected with probability proportionate to size , and then the desired number of households per cluster are selected . The method for randomly selecting households depends on the size, density, and living arrangements of the population within the cluster. In small villages, full enumeration of households, followed by random sampling, is often possible. In scattered populations, randomly selecting a direction to walk , selecting a random starting point, and sampling contiguous households is common . Random selection in urban settings can be more challenging, given the larger sampling frame and complex household types . In such settings, a common approach is to divide the geographic area of interest into zones, randomly select a zone, and randomly select a starting point within that zone. However, specific strategies must be devised for selecting households in multiple-dwelling units . The traditional EPI methodology has important limitations. Selecting geographically contiguous households, which may share key factors , could affect survey findings . The EPI method also does not include an approach for revisiting households in cases of non-response; potential bias may result if individuals who are not at home share characteristics that differ from those who are at home . Various efforts have been made to extend the EPI approach in diverse settings. Milligan, Njie, and Bennett favor compact segment sampling, a self-weighting procedure involving the selection of clusters with PPS using census data . Technologies such as Global Positioning System and Geographic Information Systems/Google Earth imagery have been advanced as ways of improving the EPI approach. Various topics have been studied using modified random walk methodologies, including adolescent social networks and HIV transmission in the U.S. , and mental health in the Balkans and Germany , although response rates have not always been higher than telephone survey response rates. In Mundt et al.'s study , over half of the original sample did not respond, while an additional 25% were living in another community at the time, leading to a final response rate of 48.5%. Overall, the literature on random walk sampling suggests that this methodology shows promise for studying a variety of health-related topics, but that it can be refined through use of web-based maps and other related technologies. The present paper describes an application of a modified random walk approach to gather social and biological data in a small Canadian community. We describe the study protocols and provide response rates for the study and for the provision of biological data. Implications of the preliminary findings for research on substance use, and suggestions for future research, are provided. --- Method This pilot study was conducted as part of Researching Health in Ontario Communities , a multidisciplinary study funded by the Canadian Institutes of Health Research that uses a mobile research lab to collect social, epidemiological and biological data in communities across Ontario . The random walk study was implemented in Port Colborne, a small city in Southern Ontario with a population of 18,599 as of the 2006 Canadian Census. This study was approved by the Research Ethics Board at the Centre for Addiction and Mental Health . --- Research Design A two-stage cluster sample approach involving the random selection of blocks within census tracts, households within blocks, and individuals within households was employed. The sampling frame was generated from 2006 Canadian Census data for Port Colborne. In 2006, Port Colborne was characterized by five tracts, ranging from 3,193 to 4,856 residents. Across these tracts were 427 blocks with a mean population of 43.56 and a mean number of households of 19.95. The total number of private dwellings was 8,519. The sampling frame was comprised of 200 households. This sampling frame was deemed sufficiently large for the purpose of developing protocols. First, a sample of census blocks was selected with PPS. CSurvey 2.0 was used to select 20 blocks using ------IJADR 2 ------PPS with replacement . These blocks ranged in size from 11 to 235 households. "Households" were defined as places of residence identified by an address number, a mailbox, and/or an apartment number. A sample of 10 households was collected from 17 of the 20 randomly selected blocks, and a sample of 20 households was collected from the three blocks that were randomly selected twice. Prior to data collection, maps for the census tracts and for each randomly selected block were prepared. The maps were used to randomly select one of the four corners of a block; the household closest to the selected corner was identified as the starting point. Next, a random number ranging from zero to the total number of households in the block minus one was selected. Then, using aerial maps, the number of households corresponding to the selected random number was counted in a clockwise direction starting with the household closest to the selected corner. The field workers were instructed to proceed from the starting point in a clockwise direction and were provided with the specific number of households to be skipped in each block in order to ensure objectivity in household selection. --- Participant Recruitment and Data Collection Each randomly selected household was contacted up to six times by a combination of methods-via letter , in person, or by phone-to request their voluntary participation. Participation involved visiting the CAMH mobile research lab, parked in a convenient location in the community, to complete a self-administered questionnaire and provide biological samples. During the first stage of recruitment, staff randomly selected 200 households and dropped off an advance letter and a flyer about the study. Field workers travelled in male-female pairs to ensure their safety. They wore CAMH photo identification badges and carried study investigators' business cards and additional project literature. On the second household visit, the field workers knocked on the doors of the randomly selected homes. If contact was not made, a second letter was left. Subsequent visits were made as needed, such that each household was visited in person up to three times, not including the first advance letter drop-off. Times and days of the week for these visits were systematically varied to maximize the chance of contact. If contact was not made, the staff tried to locate telephone numbers using available listings . Additional recruitment attempts were made by telephone, with a total of three callbacks at varying times of day and days of the week. Households for which telephone numbers could not be found were revisited in person up to six times. When contact was made, the field staff obtained permission to randomly select an adult for participation. If the resident reached was the only person living in the household and was 18 or older, they were automatically selected. Otherwise, the researchers used Kish tables to randomly select an adult within the household. Informed consent was obtained at the lab prior to data collection. Participants were compensated in gift cards; they received $25 for completing the questionnaire and $25 for providing one or both of the biological samples. Efforts were also made to raise the profile of the study in the community to encourage participation. First, the RHOC project's Community Advisory Committee, consisting of representatives from local and regional health organizations , raised awareness of the project through their networks. Second, the research team delivered a televised presentation to city council and held meetings with community stakeholders . Third, the study was promoted in community newspapers and local news channels. --- Results Figure 1 summarizes participation and refusals. Of the initial 200 households, 11 were ineligible because they were vacant or belonged to non-Canadian citizens . Interviewers were able to make contact with 186 of the remaining 189 households. Approximately 47% of contacted residents were female and 53% were male. As shown in Figure 1, in 146 of the 186 contacted households, either the residents agreed to complete Kish tables or there was only one resident in the household . A larger proportion of men than women agreed to the selection process (χ 2 = 1.92, not significant). Of the 146 residents selected for participation, 83 were men and 63 were women. As shown in Table 1, the selection process using Kish tables led to a higher proportion of men than exists in the composition of the 146 households involved in the selection process . This discrepancy can be partly accounted for by gender differences in the number of single resident households. Of the 146 selected persons, 95 agreed to participate at the time of contact . After multiple attempts, the field workers were unable to reach nine of the 146 selected persons. Three of the 95 people who initially agreed to participate ultimately did not take part in the study. The final sample consisted of 52 men and 40 women . --- Response Rate The final response rate, defined as the number of participants divided by the number of contacted households , was 49.5%. Although the intent of the first field visit was only to drop off the advance letter, field workers contacted residents in 54.3% of the households during this first visit . By the second and third recruitment visits, contact had been made in 72.6% and 80.1% of the 186 households, respectively. Additional visits and telephone calls were made to reach the remaining households. Non-contact occurred for only three eligible households. Figure 2 shows a similar cumulative distribution for participation appointments ------ --- Figure 1 --- Participation and refusals at different stages of recruitment --- Cumulative percentage of households in which contact was established or appointment was set as a function of the visit when a specific time for participants to come to the mobile lab for survey completion was set). After the third visit, 63%, or 58 of the 92 appointments, were set. Additional contact attempts were required to book the other 37% of participation appointments. --- Provision of Biological Samples Of the 92 study participants, 88 provided a saliva sample. Participants were eligible to provide hair samples only if their hair was at least 3 cm long, the minimum length needed for analysis. The individuals who were ineligible to provide hair samples were primarily men. Seventy-five participants met the eligibility criterion for hair collection; of these, seventy-four provided hair samples . --- Discussion This paper describes a modified "random walk" door-todoor recruitment strategy used to obtain a random community sample for participation in a study involving the collection of both self-report and biological data relating to mental health, substance use, addiction, and violence problems. The study demonstrated a relatively good response rate of 49.5%, which is similar to the response rate of 48.5% obtained in a recent random walk study on mental health conducted in Berlin . The study also demonstrated an exceptionally good cooperation rate on the provision of biological samples . These findings add to growing evidence that participants are willing to provide saliva samples for genetic research and demonstrate the feasibility of integrating the collection of biological data into epidemiological surveys on MSAV problems. In-person recruitment using door-to-door approaches may be especially advantageous when it is deemed important to explain to potential participants the significance of the research or the details of the project, such as how biological data will be collected and used. In the present study, trained research staff gained the trust of potential participants by showing their staff identification, providing relevant literature when requested, and answering specific questions about the project. These strategies are often not possible using other survey methods. Non-contact is a key factor affecting declining response rates in epidemiologic studies , with, for example, non-contact in telephone surveys rising due to the use of cell phones, caller ID and do-not-call lists . In contrast, the present approach maximized contact with potential participants. After six contact attempts, noncontact occurred in only three of 189 eligible households. Thus, the potential bias associated with noncontact was almost nonexistent in the present study. The present study offers several valuable modifications to the traditional random walk approach that may be applicable across diverse settings. The household selection process for the study was completed using current Taking advantage of technological innovations may be especially helpful when implementing the random walk approach in complex urban settings. Another key modification to the random walk approach was that participants were required to visit the mobile research lab for data collection, rather than having data collected in their homes. While potential participants may be reluctant to visit large study sites such as universities or hospitals , they appear to be willing to participate when small clinics, such as mobile labs, are available in their communities. With this approach, staff safety was also maximized, since they did not have to enter participants' homes. Participants could more easily keep their involvement confidential from other household members, if desired. Use of the lab also meant that all necessary research materials and data collection tools did not need to be transported into the field. Combining a door-to-door recruitment strategy with data collection in a secure, neutral location may thus be an important way of augmenting response rates, enhancing standardization of data collection, and facilitating biological sample collection. Notably, however, securing the technology and resources needed to use the mobile lab may not be feasible in regions where research resources are scarce. The study had a number of limitations which have implications for application of this method in future research. Forty of the 186 eligible households refused participation from the outset of the study. This placed a ceiling of 78.5% on the response rate and meant that demographic data on the eligible household member was not obtained, affecting analyses of contact and refusal rates. Future research could implement strategies to reduce this initial refusal rate. In this study, household members who assisted in the completion of Kish tables but were not randomly selected were not compensated for their time. A small incentive provided at the time of selection could decrease refusals at this stage, to the possible end of raising the final response rate. An important question for consideration is whether asking for the provision of biological samples was a reason for participant refusal. Unfortunately, this information was not collected in the present study. Therefore, in future research it will be necessary to assess the extent to which a request for biological data is a deterrent for potential participants. Another limitation is the cost associated with the fieldwork. We have estimated this cost at roughly $300 per participant, assuming a response rate of 50% in a sample of 200 participants, excluding compensation to study participants. Travelling costs for door-to-door recruitment were minimal in our present study due to the fact that sampling occurred in a small community. This cost could increase substantially if interviewers had to travel longer distances between clusters in large cities or rural areas. As noted above, interviewers were always sent in pairs for their security, which doubled the cost of human resources for the door-to-door recruitment component but was deemed necessary to ensure staff safety. Notably, costs of the study would diminish as the sample size increases, because some resources and tasks, such as preparation of maps and travelling to selected blocks, are largely independent of the number of participants. Another way to decrease cost would be to reduce the number of repeated visits to households. In the present study, three visits were required to make first contact with 80% of the sample. After three visits, only 63% of selected individuals had set appointments for participation. This meant that additional visits and telephone calls were required to reach the remaining 37% of households. Therefore, any reductions in the number of visits would reduce the response rate dramatically. Overall, while approaches to cost cutting may be employed, they must be weighed against potential loss in data quality. --- Conclusion Future research using the random walk method can build on the present study to investigate ways of improving on the current response rate of 50%. Strategies for converting refusals, including offering incentives at various stages in the recruitment process and providing alternative ways of participating, could be investigated. Future research could also investigate the impact of requesting biological samples on response rates and the effect of stigma on participation . Such efforts would allow for further refinement and adaptation of the proposed methodology to suit the survey and community under investigation. As Morton et al. point out, detailed information regarding recruitment and participation is critical to advancing the epidemiological literature and expanding researchers' capacity to improve survey methods. Future research is needed that directly compares sampling strategies in terms of response rates, sample representativeness, and costs for multiple recruitment strategies and data collection methods within the same community or comparable communities, using sufficiently large samples. This research could also examine several variations on the methods in order to capture the impact of different components of the method on response rates. Such a study would permit rigorous evaluation of the relative merits and weakness of different approaches for studying substance use and abuse and other health-related topics, including an assessment of whether provision of biological samples would vary as a function of the method employed. Potential applications of the random walk methodology in future research are numerous. Given that most participants were willing to provide biological data in the current study, the random walk approach for collecting both social and biological data may be useful for examining biological mechanisms underlying substance use and abuse as well as interactions between ------IJADR 2 ------biological and social factors as they relate to mental health and substance use problems . As discussed earlier in this paper, the random walk methodology may be particularly valuable in developing countries, where population and telephone listings are unavailable but general population samples and collection of biological data are desired. Applying a random walk methodology combined with collection of biomarkers would allow for objective population-level estimates of alcohol use and abuse, which are crucial for the development of evidence-based policy and programming. In developing countries, for example, studies have revealed the value of collecting biomarkers of alcohol use in settings where traditional measures of alcohol consumption are hindered by various obstacles . Furthermore, it is reasonable to posit that the random walk methodology could serve as a mechanism for dovetailing research and alcohol education and abuse prevention campaigns, including, for instance, population education on the risks of alcohol use and provision of information about available services in the community. Such an approach mirrors the principles of the original EPI, involving assessment of immunization coverage in combination with provision of vaccines. The random walk methodology also holds relevance for urban settings, with potential to help researchers overcome some of the limitations of telephone-based surveys on alcohol use by enhancing the likelihood of contact and by allowing for more detailed collection of information about participation and refusals. Overall, further research using this method can help clarify its potential applications and refine the approach for use in diverse settings.

Aims: To describe a modified "random walk" door-to-door recruitment strategy used to obtain a random community sample for participation in a study relating to mental health, substance use, addiction, and violence (MSAV) problems and involving the collection of both self-report and biological (hair and saliva) data. This paper describes study protocols, response rates for the study and for the provision of biological data, and possible further applications for this data collection method. Design: A two-stage cluster sample was derived from the 2006 Canadian census sampling frame for a small Ontario community, based on the random selection of city blocks as the primary sampling units and households as the secondary sampling units. Setting: A small city in Ontario, Canada.A general population sample of 92 participants selected randomly from households using Kish tables.A computerized questionnaire was administered to obtain self-report data on MSAV problems. Saliva was collected to study genetic vulnerabilities to MSAV problems, and hair was collected to examine stress levels (via the hormone cortisol) as they relate to MSAV problems.The study showed a response rate of 50% and a high rate of provision of biological samples (over 95%). Conclusions: Modified random walk methodologies involving face-to-face recruitment may represent a useful approach for obtaining general population samples for studies of MSAV problems, particularly those involving the collection of biological samples. Further studies are needed to assess whether this approach leads to better response rates and improved estimates compared to other survey methods used in research on substance use. Population surveys are a key tool for epidemiologists, health planners, and policy makers, providing essential information about the prevalence and correlates of mental health and substance use problems that can be used to develop evidence-based public health programming and policy. In recent years, two important trends have emerged that hold implications for epidemiological research on substance use and addictions. First is the ongoing decline in survey response rates in numerous countries around the world, which can lead to bias in population estimates due to differences in respondent and non-respondent characteristics (Atrostic,

cohort study. The SEED cohort is a population-cohort study comprising of the three major ethnic groups in Singapore [18][19][20][21][22] . Participants aged 60 years and above were selected for the questionnaire. Verbal informed consent was obtained from all study participants by a trained study team over the phone because the questionnaire was performed during Singapore's nationwide lockdown period , whereby only essential business and service providers were allowed to open e.g., food stalls, supermarkets, hospitals, utilities and transport; schools were moved to full home-based learning, restrictions were imposed on movements and social gatherings. All study procedures were conducted in accordance with the Declaration of Helsinki and approved by the SingHealth Centralized Institutional Review Board . --- SEED COVID-19 Questionnaire. SEED COVID-19 Questionnaire was adapted from the Chicago COVID-19 Comorbidities Survey conducted in the United States during March 2020 4 . The SEED COVID-19 questionnaire investigated elements related to COVID-19, including participants' awareness, concern, knowledge, and preparedness. Additionally, the SEED COVID-19 questionnaire assessed the impacts of COVID-19 on general health well-being, and participants' acceptance of digital health services. --- COVID-19 awareness and concern. Participants were asked in their preferred languages to rate the gravity of COVID-19 as a public health threat . In addition, participants were assessed on their worries about contracting COVID-19 and if they thought they would get sick from COVID-19 . The last question in this section evaluated participants' opinions on the likelihood that someone they knew would get sick from the disease this year . COVID-19 knowledge. The SEED COVID-19 questionnaire also investigated participants' knowledge on the presence of asymptomatic COVID-19 carriers . Participants were asked to rate the likelihood of a COVID-19 infected person displaying mild/no clinical symptoms and whether an infected person would die as a result, on a scale of 1 to 10 . Five COVID-19 prevention methods were listed individually and participants were asked for their views on the importance of these five methods. . --- Information sources. Participants' sources of information on COVID-19 were determined from a list of potential sources . --- Confidence in government and individual preparedness level. Participants' confidence in the Singapore government's ability to prevent further outbreak in the local community along with their preparedness in the event of another outbreak in the community were evaluated. --- General health and well-being. Participants were asked to rate how much their daily routines had been impacted due to COVID-19 . "A change in daily routine" was recorded as 'yes' when participants responded with either "a lot", "moderate" or "a little". The impact on participants' general health was assessed by asking participants if they experienced any of the following symptoms: "Lose much sleep", "Feel under stress", "Feel unable to 'face up' to problems encountered", and "Feel unhappy/depressed" over the past one month in comparison to their normal routine. The response options were "Less than usual", "No more than usual", "Rather more than usual", or "Much more than usual". Well-being affected was defined as 'yes' when participants had at least one response with "Rather more than usual" or "Much more than usual" to the symptoms. Individual acceptance towards digital health. Participants' acceptance towards digital health services software or Computer for screening of any health condition"; "Online Questions & Answers platforms") was evaluated by asking if participants had used any of these services before COVID-19 outbreak. Participants were also asked on the helpfulness of these digital health services in reducing non-essential contact between patients and health care providers and the likelihood of them using these services . Participants' comfort level in using software/ AI system to review medical reports and provide advice automatically was evaluated too . Other measurements and systemic assessments. Body-mass index was calculated as body weight divided by body height squared. Blood pressure was measured using a digital automated BP monitor . Hypertension was defined as systolic blood pressure ≥ 140 mmHg, diastolic BP ≥ 90 mmHg, physician's diagnosis, use of hypertensive medication and/or self-reported history of hypertension. Diabetes mellitus was defined as random glucose ≥ 11.1, glycosylated haemoglobin ≥ 6.5%, use of diabetic medication and/or self-reported history. Kidney function was assessed using estimated glomerular filtration rate from serum creatinine using the chronic kidney disease epidemiology collaboration equation 18 . Subjects were defined to have chronic kidney disease if GFR was less than 60 mL/min/1.73m 2 . Non-fasting venous blood samples were collected for biochemistry tests including plasma cholesterol [total cholesterol, low-density lipoprotein and high-density lipoprotein ], serum triglyceride , HbA1c, creatinine, and random glucose. Interviewer-administered questionnaires conducted in the participant's language of choice were utilized in order to obtain participant information on their demographic, lifestyle factors and medical history such as smoking status, weekly alcohol intake, monthly income , education level and housing type . Cardiovascular disease was defined as self-reported myocardial infarction, angina or stroke. --- Statistical analysis. All statistical analyses were performed using Stata 14.0 . For descriptive statistics, the mean and standard deviation were reported for continuous demographic characteristics and COVID-19 survey responses by ethnic groups, while frequency and percentage were reported for categorical characteristics. Multivariable logistic regression models were performed to evaluate the associations between demographic factors , socio-economic factors , lifestyle , and history of chronic systemic diseases , with COVID-19 awareness, knowledge, preparedness, wellbeing and acceptance towards digital health services, respectively. --- Results We had contacted and invited 745 participants to take part in the questionnaire. A total of 222 participants had rejected to take part, and 523 participants completed the questionnaire. Among the participants, 51.4% were female, 92.4% had formal education and majority of them had history of hypertension. The mean age was 72.3 ± 7.7 years . 2 presents participants' responses to questionnaires pertaining to COVID-19 awareness, knowledge, preparedness, well-being and acceptance towards digital health services. Among the participants, the mean score on the perceived seriousness of COVID-19 was 7.6 ± 2.4 . 33.5% participants responded being "very worried" about getting COVID-19, 35.2% stating that they were "a little worried" and the remaining 31.4% participants expressed that they were "not worried at all" . Across ethnicity, among the 191 participants who perceived that they "will not get sick from COVID-19" , 58.1% were Indians, 20.9% were Malays and 20.9% were Chinese . About 56.7% Indian participants responded "not worried at all", compared to 18.1% of Malay and 20.0% of Chinese participants. Similarly, when asked about how likely someone whom participants knew might get sick from COVID-19, 213 participants responded "not at all likely", of which 62.9% were Indians, 16.9% were Malays and 20.2% were Chinese . In multivariable analysis, Indian elderly were more likely to "not feel worried about getting COVID-19" as compared to Malays . --- COVID-19 awareness and concern. Table --- COVID-19 knowledge. Of the participants, 75.5% know that COVID-19 carriers can be asymptomatic; and ≥ 92% of them agreed that the listed five prevention methods are important in mitigating transmission of COVID-19 . On average, participants reported a perception score of 5.3 ± 2.3 on the likelihood for "infected person displaying no or mild symptoms" . On the likelihood perception of whether COVID-19 infected person will die from the COVID-19, Malay participants reported a perception score of 6.3 ± 2, compared 5.5 ± 2.5 in Chinese and 3.4 ± 2.8 in Indians . Multivariable analysis further showed that, participants residing in smaller public housing flats were more likely to be unaware that COVID-19 carriers can be asymptomatic . --- Information sources on COVID-19. Source of COVID-19 information was obtained mostly from: TV , newspaper , family and friends and radio . Less information was obtained through smart device applications such as internet, social media and messaging application . While the least information was obtained through hospital/polyclinic/GP and posters/leaflets . --- Confidence in government and individual preparedness level. Of the participants, 86.8% were "very confident" or "somewhat confident" with government in preventing a further widespread outbreak in the local community; and 66.2% of the respondents reported "very prepared" or "somewhat prepared" if a widespread outbreak happens locally . Multivariable analysis further showed that, compared to Malays, Chinese participants were more likely to expressed feeling unprepared if there were a further widespread . General health and well-being questionnaire. Although 30.4% of respondents reported that COVID-19 had caused their daily routine to "change a lot" , 69.4% of the participants did not experience more stress and unhappiness. Similarly, 78.4% reported not losing sleep more than usual and 80.5% participants responded that they were not experiencing more difficulties in facing up to problems encountered with COVID-19 . Multivariable analyses further showed in Table 3 that older participants were less likely to report change in daily routine , whilst participants with higher income were more likely to experience change in daily routine. Compared to Malays, Indians were less likely to experience change in daily routine ; con- versely, Chinese were more likely to perceive so. On the other hand, compared to Malays, Indian and Chinese elderly were more likely to perceive that their well-beings were affected. --- Assessment on individual acceptance towards digital health. Of the participants, 98.1% reported not using any digital medical services for doctor consultation or medical follow-ups prior COVID-19 outbreak; and 47.8% responded "no" or "unsure" that digital health services would be helpful in reducing non-essential contact between patients and doctors . A total of 55.6% participants reported either "not at all likely", or "somewhat unlikely" in using these digital medical services if COVID-19 pandemic were to continue . Multivariable analysis shown in Table 5 presented that, compared to Malay participants, Indian participants were less likely to perceive that digital medical services were helpful in reducing non-essential contact . Participants with higher income and higher educational level were more likely to perceive that such digital services were helpful. Furthermore, higher income individuals were also more receptive to use digital medical ser- vice if the pandemic were to continue. Finally, older participants were less receptive to use digital medical service . --- Discussion In this multi-ethnic Asian elderly group, we evaluated the pandemic's impact on the participant's well-being, as well as their knowledge and awareness of COVID-19. Overall, there was good consensus that COVID-19 is a serious public health threat with majority of participants showed high level of awareness on the asymptomatic transmission nature of COVID-19, as well as the relevant preventive measures to mitigate transmission. However, relatively few respondents were receptive to digital health services as an alternate means for medical consultation if the pandemic were to continue. This study presents present novel data on the perceptions of a multi-ethnic Asian population on COVID-19. These findings will be useful for policy makers to examine the effectiveness of current public communication strategies related to COVID-19. The observed findings also highlight the need to improve digital health acceptance and adoption among elderly as we move towards a new normal, post COVID-19. Similar to our study, in a cross-sectional survey conducted by Wolf et al. in the US among adults with chronic condition during the onset of the pandemic 4 , most of the US participants were aware of the symptoms and prevention methods for COVID-19. A stark difference, however, is the response on preparedness for the outbreak. In the US study, around 20% of respondents stated they were prepared for the pandemic and around 10% of them indicated their confidence in the government's ability to handle COVID-19. Similarly, in a study done in Russia, only 15% of the study population felt that their country was well-prepared and more than 50% of the population reported that they had low trust in the government and local authorities despite being well-informed on COVID-19 measures 23 . Our study showed that close to 70% of respondents were confident in the Singapore government's ability to limit the widespread of COVID-19, with more than 60% of respondents indicated that they were prepared to handle a similar pandemic. Given that the US team found that the low rate of confidence was associated with a low health literacy and individuals who belonged to a non-White race, this exacerbates the fact that health literacy is a key to understanding government advisories as well as mediating the impact that the pandemic has on an individual's mind set and health 1 . Additionally, health literacy includes one's ability to receive information and recognize whether they have been affected. A study done by Okan et al. on German participants aged 16 years and above with a mean age of 45.6 years, found that around 40% of respondents found it hard to identify information on how to recognize COVID-19 infections and majority of them felt confused by the information presented 15 . This adds to the perennial problem of poor readability of health information in various sources including the internet 24 and impacts one's health literacy. It also relates to the respondents' perception on the reliability of their sources, indicating the importance of gaining the trust and confidence of the public in the course of the pandemic. With lower health literacy, patients lack the ability to understand the seriousness of the pandemic and the preventive measurements needed to take to prevent contracting the disease. In Singapore's context, the high rate of COVID-19 awareness could be attributed to the effective dissemination of COVID-19 related information and knowledge in Singapore during the early phase of pandemic 25 . While most people are acting in a socially responsible way, there is still a small percentage of people ignoring preventive measurements and protective behaviour due to the lack of knowledge and awareness towards COVID-19 26 . It is therefore important that the public, especially the elderly, to have some degree of awareness and knowledge on COVID-19. In our study, we found that COVID-19 caused an increase in respondents' stress and reduced happiness level as compared to their sleeping habits and resilience level. In comparison to studies conducted by Kivi et al. on the Swedish population and van Tilburg et al. on the Netherlands population, respondents indicated an equally high level of wellbeing as compared to previous years 27,28 . It is important to note that the Netherlands citizens had to practice social distancing but not social isolation, and the Swedish older adults were still carrying on with their daily activities as the study was conducted during the initial part of the pandemic. Our study was conducted during the lockdown period in Singapore, where citizens had to stay at home for a prolonged period, which could be an explanation for the difference in wellbeing results. The comparison of our results to the mentioned studies is a good indicator that wellbeing should be monitored closely among the elderly especially since there are other factors such as government policies and lifestyle factors that could play a role. In terms of ethnicity differences, compared to Malays, Indian participants were five times less worried about getting COVID-19 , and about two times were less aware that a COVID-19 infected person can be asymptomatic . Compared to Malays and Chinese, there were more Indian individuals who reported that they had no changes in their daily routines compared to Malay and Chinese participants . In contrast, about six times more Chinese participants felt that their well-being had been affected by COVID-19 and three times more Chinese felt less prepared compared to Malay and Indian participants . These results suggest that less knowledge, awareness and concern of COVID-19 and the low COVID-19 death rate in Singapore could lead to optimism bias which makes individuals less likely to change their actions or behaviour to curb the spread of disease 29,30 . It is important for government bodies to understand and evaluate if there is a knowledge gap on the current health issues among different ethnicities and rectify the problem promptly. The first outbreak that Singapore had to manage in the twenty-first century was the SARS pandemic in 2003 31 . Post-SARS crisis, Deurenberg-Yap et al., found that Singaporean adults had low knowledge score on SARS and control measures even though they expressed a high level of public trust in the government 31 . Fast forward to 2020 during the COVID-19 pandemic, we found high government trust and good awareness and compliance with public health measures. The relative increase in public knowledge levels over the years could be a testament to the government efforts in being more deliberate with raising awareness and the public's efforts in being more informed about COVID-19. The COVID-19 pandemic had caused a massive acceleration in the adoption of digital technology with many clinical facilities reduced or even ceased. Healthcare providers had also remodelled physical services to encourage patients to seek care online instead 32,33 . The use of digital technology had been described as "electronic personal protective equipment" and had brought upon advantages including convenience, less exposure from physical interactions and reduced cost 34 . However, it is important to consider patients' acceptance when addressing the feasibility and sustainability of digital solutions in healthcare. Our findings showed that almost all participants did not use digital health services prior to COVID-19 pandemic, which could be explained by the lack of digital literacy and understanding of these services. This corroborates with an earlier study that reported the elderly had reduced patient acceptance of mobile technology in emergency services 35 . Almost half of elderly respondents perceive that these services are not helpful in reducing non-essential contact in clinic setting and have less acceptance to such services. In contrast, our findings indicated that participants with higher income and formal education do find digital health services useful and were more likely to use the services compared to participants of lower income and without formal education. It showed that individuals of lower income, less resources and lower education level have lower acceptance of digital solutions in healthcare 36 . This highlights the crucial need for administrators and providers to address health care accessibility and public health awareness among underprivileged individuals as the pandemic situation persists. Our study had several strengths. First, our study sample was of substantial size, and comprised of the three main ethnic groups in Asia. Secondly, our data were less prone to recall bias and response error as the survey was conducted while the roll-out of COVID-19 measures were still fairly recent back then. Thirdly, in our multivariable analyses, we were able to control for multiple relevant confounders including demographic, social economic status and systemic comorbidities. However, our study has a few limitations. First, this questionnaire study was conducted on a selected group of SEED study, thus potentially introducing selection bias. In addition, while we assessed digital acceptance in the questionnaire, we did not further evaluate participants' digital literacy level, a factor which might influence one's acceptance of digital health services. Lastly, our findings only captured responses during the initial stage of the pandemic. The responses and behaviour captured then, may continue to change with time as the pandemic situation evolves. --- --- Competing interests The authors declare no competing interests.

This study aimed to determine COVID-19-related awareness, knowledge, impact and preparedness among elderly Asians; and to evaluate their acceptance towards digital health services amidst the pandemic. 523 participants (177 Malays, 171 Indians, 175 Chinese) were recruited and underwent standardised phone interview during Singapore's lockdown period (07 April till 01 June 2020). Multivariable logistic regression models were performed to evaluate the associations between demographic, socio-economic, lifestyle, and systemic factors, with COVID-19 awareness, knowledge, preparedness, well-being and digital health service acceptance. The average perception score on the seriousness of COVID-19 was 7.6 ± 2.4 (out of 10). 75.5% of participants were aware that COVID-19 carriers can be asymptomatic. Nearly all (≥ 90%) were aware of major prevention methods for COVID-19 (i.e. wearing of mask, social distancing). 66.2% felt prepared for the pandemic, and 86.8% felt confident with government's handling and measures. 78.4% felt their daily routine was impacted. 98.1% reported no prior experience in using digital health services, but 52.2% felt these services would be helpful to reduce non-essential contact. 77.8% were uncomfortable with artificial intelligence software interpreting their medical results. In multivariable analyses, Chinese participants felt less prepared, and more likely felt impacted by COVID-19. Older and lower income participants were less likely to use digital health services. In conclusion, we observed a high level of awareness and knowledge on COVID-19. However, acceptance towards digital health service was low. These findings are valuable for examining the effectiveness of COVID-19 communication in Singapore, and the remaining gaps in digital health adoption among elderly. As of end January 2021, the coronavirus disease 2019 (COVID-19) has infected approximately 100 million people, leading to more than 2 million deaths globally 1 . This global pandemic has brought upon unprecedented challenges worldwide. Given the rapid spread of COVID-19, a society's awareness and knowledge of COVID-19, key preventative measures (e.g., wearing masks) and acceptance of new models of care (e.g., video-consultations) 2 is important. Many communication channels have been concurrently swamped by a deluge of misinformation (hence, dubbed an "infodemic") 3 , further highlighting the need for policy makers and healthcare providers to provide reliable information that is easily understood and accessible 4,5 . Adequate health literacy amongst the general population is also critical to complement government-implemented measures. Having a high level of awareness about recommended preventive health behaviour (e.g., mask wearing, hand hygiene) are essential safeguards against the community spread of COVID-19. All of these can significantly improve disease prevention, timely diagnosis and management.

Introduction Conflicts between parents and children tend to increase in frequency at the transition to adolescence. Quarrels and bickering over everyday issues are commonplace in parentadolescent relationships [1]. Pre-adolescents begin to challenge the rules and norms put in place by parents, and they seek new modes of independence [2,3]. Young people are becoming independent and engaging in the social world-they are still dependent on caregivers in some key domains while simultaneously building their own voices and opinions. Early and pre-adolescence are marked by an increase in negative emotional states as children transition and move to the next developmental phase of life [4]. In turn, parents perceive adolescence as the most difficult time of childrearing [5]. However, researchers agree that conflict in this transitional period is normative and functional in transforming family relationships [2]. For parents and pre-adolescent children years old) in today's digital world, conflicts about technology and screen use pose a new and escalating challenge for families [6]. Screen-use conflicts take many forms including the appropriate age to get a smartphone; signing up for social media accounts such as Facebook, Instagram, and Snapchat; and the appropriate use of screen devices [7]. Screen-use conflicts are often driven by caregiver's fear of the potential negative effects of screen use. Such anxiety is amplified by media coverage and popular science publications, which portray digital devices as harmful to healthy development and growth [8][9][10] despite little to no scientific evidence to support these fears [11]. Though hundreds of studies have been conducted on screen use and screen time [12], the literature remains inconclusive. However, headlines in the media regularly suggest that screen time causes a host of negative mental and physical health outcomes [13]. Consequently, parents fear that screen use may degrade mental well-being [14], increase aggression [14], and lead their children to become addicted to screen time [14]. Therefore, studies suggest that many parents view screen time as largely negative. In contrast to parents' opinions about screen time, we know relatively little about pre-adolescents' perceptions of screen use. The scarce literature that is available suggests that young people view screen use as an opportunity to connect with their peers, assert their autonomy, and learn about the world [15]. Despite the insights from studies of parents' concerns and the scarce literature of youth's perceptions of screen use, no one to our knowledge has systematically studied screen-use conflict in naturalistic conversations. Current attempts to understand both parent and pre-adolescent perspectives and screen use have been shallow, focusing on mere time metrics and reliant on self-report measures that have been shown to either be poorly related or completely unrelated to screen use [16,17]. Inconsistent conclusions and poor statistical methods render a call to action for a different methodological approach to understanding screen-use phenomena [13]. In particular, qualitative analyses of naturalistic conversation can offer tremendous insight into pre-adolescent perspectives and parent-child screen-use conflicts for two reasons. First, it is important to know what youth actually think about screen use. Doing so will help us understand pre-adolescents' perspectives, feelings, and motivations. Second, by better understanding young people's views on screen use, we are better able to investigate parent-child conflicts about screen use. Currently, pre-adolescent views have been absent from screen-use conflict discussions. However, one possibility is that conflicts arise because youth think about and use screens differently than parents. Learning about youth perspectives also helps to inform our understanding of parent and pre-adolescent screen-use conflicts. Thus, the following questions remain: how do conversations about screen use unfold between parents and children, and what are the core themes of screen-use conflict? In the current study, we examined screen use conflicts between pre-adolescent children and their mothers using qualitative thematic analysis. We analyzed both parent and child perceptions to gain insight into their views of screen use. This allowed us to examine screen-use conflict within real-world parent-child interactions, thereby enabling us to identify both unique and familiar aspects of parent-child conflicts in the context of screen time use. --- Materials and Methods --- --- Procedure Participants completed questionnaires on a computer in the lab prior to engaging in a 4-min videotaped conflict discussion. The conflict topic was selected from one of the questionnaires for which mothers and children identified the top 3 conflict topics they argue about. The researchers chose the topic rated as the highest intensity from those two lists for the dyad to discuss. In the present study, we only analyzed transcribed dyadic data in which screen use was discussed. --- Data Analysis Strategy To analyze the screen-time conflicts between parents and pre-adolescents, we used qualitative thematic analysis [18]. Specifically, the first and second authors separately analyzed the data following Braun and Clarke's recommendations. We proceeded with five steps. First, we read and re-read all transcripts to familiarize ourselves with the data and briefly discussed our initial interpretations. Second, we generated codes by randomly selecting 20 transcripts . Next, we conferred on initial codes and then selected and coded 20 new random transcripts using the codes from the first set. This procedure was repeated for the third and fourth sets of 20 random transcripts, applying all previously generated codes to a subsequent set. After going through this procedure with a total of 80 transcripts, no new codes emerged and we therefore stopped coding, following standard procedure [18]. Third, we evaluated generated codes, and we named and defined overarching themes. Fourth, the authors met for an analysis session, which involved discussing, comparing, and verifying the themes generated by each author. Specifically, themes were verified by cross-referencing the thematic scheme with the transcripts to validate the themes. As such, we re-read the transcripts and referenced the thematic scheme while reading. Finally, the themes were reviewed by two external readers to validate the credibility of the proposed themes. Child did not obey the parent to stop using screen time --- Results --- Perceptions of Screen Use In the early stage of the analysis, we found 58 unique codes-29 for parents and 29 for children. Following our data analytic strategy, we first organized these codes into themes. We identified a total of five themes and various sub-themes. These themes describe the full spectrum of the perceptions of the parent and pre-adolescent screen-use conflict. Themes were screen time , the effects of screen use with the sub-themes of positive effects and negative effects, balance with other tasks including sub-themes of good balance and screen time instead of other tasks, rules, and reasons to use screens. All five themes were the same for both parents and children, but the sub-themes differed between parent and preadolescents. A comprehensive list of all themes and subthemes differentiated by parents and pre-adolescents is shown in Table 2. The first column contains parent themes. The second column contains pre-adolescent themes. Headers with bolded text represent themes. Underneath each theme is a bulleted list of subthemes. Below, we separately discuss all themes and subthemes for parents and children. --- Rules Rules Frustration: not following rules Frustration: parents not following rules Frustration: not enough flexibility --- Balance Balance Spending time on screen instead of something else Good balance Good Balance --- Parental Perceptions of Screen Use Screen Time: One central theme of screen-use discussion is the amount of time spent on devices. In the sub-theme of too much time per child, parents were generally worried about the amount of time their children spent on screens both for school and recreational use. Parents largely commented that their children spend too much time in front of screens. In addition, parents noted that they wanted their children to initiate a decrease in the amount of time they spend using screens, saying things such as "I would like you [pre-adolescent] to stop watching your screen yourself instead of [me] asking you to". Moreover, parents often referenced that their children could not accurately track the time they spent using screens . Parents also referenced their inability to teach their child how to better spend their time and referred to children who use screens as lazy. The parental language of how to better spend time indicated that screen use is, in their opinion, not a valid or productive way for a child to spend time. Generally, parents perceived screen use as inappropriate use of time and argued that their children should be doing something more productive, saying "You have other things you could do but you waste your time on the iPad". Effects of Screen Use: The effects of screen use were a main theme, with both positive and negative effects being reported. In terms of positive effects, many parents acknowledged the positive effects screen use can have on their children. Parents identified three main areas influenced by screen use-socio-emotional development, family dynamics, and educational/academic. For socio-emotional development, many parents recognized the importance of screen use as a way to communicate with friends. Though they often referred to screen use as inferior to offline communication, they admitted that it was the way youth interact and thus may have some benefits to social development. Moreover, screen use was referenced as a family activity, as parents perceived screens as an opportunity to play games or watch digital content as a family, thereby improving family dynamics. Finally, parents recognized the positive educational effects of screen use. Parents generally praised screen use when referring to academic outcomes such as learning in the school setting. In the negative effects of the screen use sub-theme, interference with healthy development was a common concern. Parents construed screen use in all forms as a source of disruption in the healthy development of their child. Parents identified multiple areas that are influenced by screen use including social/emotional development, physical development, cognitive development, and moral development. First, effects on appropriate social/emotional development, which refers to the frequent reference of the parents' fear that screen use may cause cyberbullying, social isolation, and less face-to-face socialization. For example, parents referred to screen use as causing less motivation to leave the house. Second, effects on physical development included concerns from parents about how screen use interfered with time spent outside, that it led to an absence of interest in physical activity, and that it led to a disruption of sleep. For example, one parent brought up concerns of blue light causing headaches, saying "Do you think it's causing you headaches? Looking at a screen at night?" The third was the effect of screens on cognitive development, which refers to the regular references of parents' that the use of screens is cognitively taxing, leaving no time to truly relax. In addition, there was a pattern of parents noting that screen use stunts creativity and reduces imaginative thinking. For example, one parent said "Video games take away your imagination, you don't need to think, they are rotting your brain". The final area within the negative effects of screen use was moral development, which refers to the frequent reference of the parents' association of screen use as the source of lying. Parents brought up accounts of their child lying about their screen use, the content of their screen use, and sneaking devices. For example, parents said things such as "Yeah, I think you sneak it a lot too. I think you tell me you're going to bed and then you listen for me to come upstairs". In addition, there was a pattern of concern regarding the violent and potentially inappropriate content of video games, YouTube videos, and other online spaces. Parents made numerous references to the predatory nature of video games and screen applications, including their concern that they are designed to be addictive and destructive to children's health. Balance: An overarching theme in the parental perceptions of screen use was the balance between screen use and other tasks. The sub-theme of spending time on screens instead of something else refers to the common complaint made by parents that screen use prevents their child from completing necessary tasks such as schoolwork and chores. In addition, they noted that screen use also took precedent over all other tasks such as reading, playing an instrument, or learning a new skill. Parents often commented that "So you should be outside doing things or reading a book, things that expand your mind like playing the piano" or "You used to read all the time before you had a phone" On the other hand, the sub-theme of good balance refers to a pattern of parents noting there was a balance between screen time and tasks such as homework completion, saying things such as "I don't mind when you play on the computer when you get your other things done, which you usually do". Though this was not the dominant perspective, many parents still noted that balance was present due to using screen time as a negotiating token. Rules: Rules surrounding screen use were also a common theme including sub-themes of frustration and the necessity of rules. Parents were often frustrated and concerned with how frequently their children disregarded the set rules regarding screen use. In most discussions, parents mentioned things such as "So, yeah, that is definitely something that annoys me to no end that you can't turn off immediately when I say hey, turn it off". Though there was often a mutual understanding of the necessity of rules surrounding screen use, with pre-adolescents noting things such as "Yeah, I think it is okay. Limit is okay". Parental frustration was more common. Reasons for Screen Use: An important theme that arose was the reason for screen use. In the sub-theme of acceptance, parents' general disposition was that they did not understand why their pre-adolescent is so keen to play and interact with their screen. They often referenced a generational gap as the reasoning for their lack of understanding, noting "It's hard because it was never a part of my life really growing up. So I don't really understand the like, I don't . . . I can't empathize with you, the whole, you know, wanting to do it so bad" or "We had TV but that's it". Though some parents used their lack of understanding as a justification for less screen use for their young adolescent, others chose to accept that they will not understand and instead tried to embrace the new digital landscape, saying things such as "I think I've come to a place of accepting . . . that this is just a part of the world that you guys live in". In the social sub-theme, there was an overall parental consideration that screens facilitate social communication and connection, and that these are some of their primary uses. --- Pre-Adolescent Perceptions of Screen Use Screen Time: In contrast to parents, in the sub-theme of "screen time is fine", child pre-adolescent participants tended to not perceive the amount of time they spent online and using screens as problematic. In other words, although they acknowledged the large amount of time using screens, they did not think it was too much. Interestingly, in the subtheme of parent screen time, pre-adolescent participants referenced their parents' hypocrisy in screen time and screen use. For example, they noted that their parents used screens as or more often as they did, and their parents would not engage with them if they were using digital devices. In one discussion, a pre-adolescent said "You still don't love me and you don't give me enough attention. You spend more time on the laptop than with me. And it's not just, and it's not just now. It's before, you use your laptop and phone". Effects of Screen Use: The effects of screen use were a main theme, with both positive and negative effects as sub-themes. In the positive effects of screen-use sub-theme, many pre-adolescents acknowledged the positive effects of screen use. The social and emotional sub-themes focused on how pre-adolescents perceived the use of digital devices and screens as adding value to their lives and facilitating meaningful connections, often referencing the collaborative nature of online games. They noted screens helped them to feel more connected to the world. The sub-theme of fun and engagement focused on the importance, ease, and joy of using digital devices to communicate and socialize with their friends. In fact, pre-adolescent participants suggested they preferred online over in-person interaction because it feels safer and are in more control of "how" and "when" they socialize. Finally, the sense of control/safety sub-theme focused on pre-adolescents' desire for online over in-person communication. The desire to communicate online instead of offline suggests there is a sense of safety in their belongingness online, saying they were "comfortable in [their] little bubble". Pre-adolescents noted few negative aspects of screen time. For the family dynamics sub-theme, pre-adolescents shared their parent's concern about screen dependency and viewed screen time as a source of interference in familial dynamics. For example, they referenced fighting with siblings over the use of devices, differences in sibling privilege in screen time, and fighting with parents about screen time. In one case, a pre-adolescent participant said "We fight a lot about this [screen time], and I don't like when that happens". Balance: The balance of screen use was a main theme, with good balance as a subtheme. In the sub-theme of good balance, pre-adolescents often thought they were doing a good job of completing other necessary tasks and "earned" their screen use. In response to comments from parents about doing other activities such as reading or engaging in thoughtprovoking activities such as learning a new skill, they mentioned how video games or online activities include a lot of reading and problem solving. In addition, pre-adolescents were often open to negotiating screen time for time spent on other things such as reading or chores. Rules: The balance of screen use was a main theme, with frustration regarding a lack of flexibility in rules, parent not following rules, and the necessity of rules as sub-themes. In the sub-theme of frustration , pre-adolescents often mentioned frustration regarding screen use rules, similar to what parents noted. However, they commented on the lack of flexibility from parents in their screen-time rules and noted they did not feel like they had any say in how the rules were negotiated. Preadolescents felt their voice and concerns were not taken into consideration when setting up screen-time boundaries. Furthermore, in the sub-theme of the parent not following rules, pre-adolescents referenced the hypocrisy that their parents did not have to follow the same screen-time rules that were implemented for the child. They noted things such as "Well, you [parent] and dad are on your phone at the table all the time and I can't be, which, like, isn't fair". Interestingly, in the sub-theme of the necessity of rules, pre-adolescent understood and recognized why screen use rules were necessary and were not upset that baseline rules were in place, saying things such as "Turning it off at night is good for me so I don't get notifications". Reasons for Screen Use: Reasons for screen use was a main theme with recreational, normality, social, and educational sub-themes. In the recreational sub-theme, pre-adolescents often referred to screen use as recreational and noted that screen use was something to do when bored or when there is nothing else to do. In the social sub-theme, pre-adolescents referenced screen use as a way to communicate and connect with their friends either within a game setting or just chatting. For example, one pre-adolescent summed it up succinctly, saying "They're fun. It's a fun way to connect with your friends. Have fun with them even when you can't like be with them in person". In addition, in the educational subtheme, there was a strong pattern of pre-adolescents referencing the educational uses of screens both inside and outside of school, saying things such as "Uhm, sometimes it's like educational, like, uhm, game theory that teaches you a lot of things, like, for example, like, it teaches us about math like for like numbers like the death counts in Disney use math. Like, I learned how much land that a lion needs to feed itself". Finally, in the sub-theme of normality, pre-adolescent participants frequently referenced the normalcy of screens in their lives. They noted that screen use is simply a part of the natural order of the world and they could not imagine a world without screen technology or how they would function in such a world. They often mentioned how commonplace video games, mobile phones, and tablet devices were in their peer groups. Pre-adolescent participants also spoke about the lack of understanding from their parents about why they enjoy using screens. They referenced parents not understanding the depth of their socialization or the joy their online lives bring them. They noted this comes from a generational difference in screen use. Pre-adolescents often reported that their parents did not know how to use devices, nor did they understand video games or the nuances of online communication. They also referred to devices as a source of entertainment and a better alternative to "less fun" activities like reading books. In addition, they referred to their parents as "old fashioned" for their lack of understanding. --- Discussion In the current study, we examined screen-use conflicts between parents and preadolescents using qualitative thematic analysis to investigate two gaps in our knowledge base regarding screen use. First, we observed real-world parent-child interactions to get a better understanding of the parental, but especially pre-adolescent, perceptions of screen use, since the latter are almost fully missing in screen-use literature. Second, we aimed to better understand the gap between the screen-use perceptions of parents and their children to start disentangling the source of conflict in screen-use discussions. We found that parents and children were divergent in their perceptions of screen use. Though similar themes arose, the pre-adolescents' values and attitudes toward screen use were oftentimes in opposition with their parents. Parents mostly reported that their children spent too much time on their devices, had problems with following screen-time rules, and were not able to find a balance between screen use and other tasks. Though parents reported both positive and negative consequences of their children's screen use, their perceptions were mostly focused on the negative. Parents acknowledged that technology could be useful for education and socialization. However, they mostly saw it as a threat to healthy social, cognitive, and moral development, as well as in direct opposition with their child's ability to be productive. Children generally reported that their amount of screen time was fine for them or could be increased, were frustrated about the inflexibility of their parents regarding screen-time rules, and were mostly able to balance screen time with other activities and tasks. In contrast to their parents, pre-adolescent perspectives did not view screen use as threatening or worrisome. They focused on rebutting their parents' concerns by emphasizing the delight screen activities brought them socially, creatively, and cognitively. Our first aim was to bridge the knowledge gap regarding pre-adolescent perceptions of screen use through observing screen-use discussions between parents and their children. We found that pre-adolescents perceived screen use as a joyful and often social activity. For example, they perceived screen use as natural, valuable, recreational, and essential to their ability to socialize and explore their interests. They were not worried about the amount of time spent using screens and instead often expressed wanting to have even more screen-time. Though they recognized and respected the need for boundaries around screen use, they felt their opinions and reasoning for flexibility in screen-use rules were lost in parents' misunderstanding of the role screens play in their lives. In contrast to their parents, pre-adolescents generally had more positive views of screen time; however, they also acknowledged that screen use is a source of interference in family dynamics, such as fighting over devices with siblings or arguing with parents about screen use. Though past literature on pre-adolescent perceptions of screen use has been limited, the themes we identified in the current study were consistent with past findings [19]. In general, children seemed to know about the potential negative effects of screen use but experience the wonders of their digital world and have a more nuanced understanding of what screens are used for and how to interact with them. They saw screen use as natural to their development and not disruptive to their productivity. However, it is important to note that capturing the child's perspective of screen use was difficult compared to evaluating parental perception. Given the unstructured nature of the conversations between parents and children, the parent often dominated the conversation and guided the child's answers to align with their perceptions, leaving less opportunity for children to express their perceptions without bias. In addition, pre-adolescents were often quiet and simply did not engage in the conversation. Thus, although we got an impression of the pre-adolescent perceptions, our overall observation was that many children withdrew from the discussion, thereby limiting our capacity to capture the child's perspective. Our second aim was to bridge the gap between parental and pre-adolescent perceptions of screen use to better understand where screen-use conflict originated from and how these conflicts might be prevented in the future. In addressing this question, we identified two patterns within the analysis of our themes and sub-themes. First, screen-time conflicts could be partly explained from a developmental perspective: much of the conflict discussions were focused on the battle between autonomy and authority between children and parents. On the one hand, parents expressed a strong desire for their children to obey rules put in place for screen time and they became frustrated when children disobeyed. As noted in our results, parental participants frequently referred to their child not ending screen use when asked. On the other hand, children desired to express and direct their own screen time use and felt infringed on when they are not allowed to be autonomous. Specifically, we found that pre-adolescents were aware that having cell phones and screen-time privileges allowed for freedom. In addition, children wanted trust in their knowledge of appropriate digital hygiene and their ability to censor content. Moreover, they often argued that screen time and the use of digital devices did not undermine other obligations such as participating in extracurricular programs, house chores, and homework. The nature of these arguments was indicative of children seeking the autonomy to govern their own time. Though these themes did indeed contain screen-use content, underlying this surface content are age-old themes centered around authority and autonomy. From our view, screen use seems to be a proxy for a typical parent-child relationship dynamic observed within other contexts and over many past generations. Such results support prior research that pre-adolescence is characterized by a process of changes toward autonomy and is associated with oppositional interactions between children and parents [20]. In order to deepen our understanding of family dynamics in the digital age, it seems important to remain cognizant of developmental themes such as increases in parent-child conflict that have long typified this developmental transition. It may also be important to integrate theory and new insights about perceptual and interpretation differences around screen time to build guidelines that help parents and children better navigate conflicts in the digital age. For example, self-determination theory could be useful for understanding screen-time conflicts. SDT posits that the motivation to self-regulate or change behavior can be sparked either internally or externally . Accordingly, when parents foster their children's internal motivations , they are bolstering their child's innate natural process to become intrinsically motivated to be intentional, internalize, and maintain change toward healthier behaviors and development [21]. More specifically, parents can help build behavior change through autonomy support by providing structure in a democratic manner, which respects children's interests and feelings and builds trust [21,22]. With respect to screen use, SDT suggests parents should start a dialogue with their children that is open and interested in their children's thoughts and feelings about screen use and time management. In addition to the insight of a developmental lens, a second pattern that arose in conflict discussion is that it seems to be the case that today's parents are faced with an experiential gap with screen-based technologies-they have never lived in a world where social connections, entertainment, and school/education exist at the hybrid boundary of in-person interactions and on screens. Though there have always been generational differences in technology and media , screen use appears to be a new challenge. Children perceive screen use as a socialization tool that provides meaningful connections. In addition, they thought of screen use as space to exercise their creativity and problem-solving skills. Finally, they consider screens as an extension of their offline lives, which has been referred to as hybrid reality: the constant interaction between online and offline spaces without clear boundaries [13]. In contrast, most parents noted that video games do not have real-world relevance and that social interaction on screens is less "real" compared to face-to-face interaction. That is, parents feel socialization on screens is inferior to real-world interactions and thus do not recognize the concept of hybrid reality themselves. This notion undermines the reality of the pre-adolescents' perception that their online socialization is meaningful while simultaneously confirming parents do not perceive screens as a part of "real" life. By missing the constantly interacting offline and online worlds of their children, parents are unable to fully grasp the experience of their child. By investing time to understand the blended online and in-person experiences of young people through open dialogue and playful digital interaction, parents would be better able to grasp the multi-faceted identity of their children's hybrid reality. --- Limitations and Recommendations While this study presented unique and novel findings, its limitations must be noted. First, people are unreliable when recalling details about their use of social media or other digital technologies, to which pre-adolescents are especially prone [16,23]. Thus, future research should be designed to capture pre-adolescent perceptions without the burden of parental interruption and provide support for accurate recall. For example, researchers could utilize structured stimulated recall interviews [24] to better capture children's perceptions and gain more insight into the discrepancies of screen-specific parent-child perceptions. Further, structured interviews with specific questions regarding screen use could provide insightful information. Moreover, our discussions invited only the mother as the representative of the parents to discuss with the children. As some of the children mentioned they enjoy playing video games with the father, the discussion dynamic might have been different if it was a father-child interview or an interview with other primary caretaker figures. For example, fathers often engage in more play behavior than mothers, which could lead to different conversations regarding screen use [25]. In the future, it would be useful to investigate interactions with other caregivers regarding screen-time discussion. --- Conclusions In general, we found that parents and children have conflicts around screens, and they hold different perspectives and place different values on screen use. Our study confirms many parent perceptions that previous research has found, and we contribute to the preadolescent perspective that has been lacking in previous research. Most importantly, young people are more open to how screens can be used for a wide variety of life domains but are also willing to compromise about screen use with their parents. Despite the differences between parents and children, they all recognize the potential costs and benefits of screen use. Importantly, while navigating screen-use conflict, they are simultaneously navigating normative developmental processes. During the digital age, youth have not evolved to be entirely different beings, nor has the parent-child relationship transformed as a result of digital interaction [26]. Children will always seek, and have always sought, love, validation, and safety from their primary caretakers while gaining their autonomy [20], whether the conversation is about the use of the new family radio or more time on the gaming console. Conflict and tension are a natural part of family dynamics, especially during puberty and family transition [27]. However, the current technological landscape-in which offline and online worlds are integrated and hard to disentangle, especially for young people-poses a unique challenge in human history. Thus, there are both familiar and novel challenges that parents and children will need to navigate within our new digital ecosystems. In order to address these challenges, we need to change the social messaging and media discussion around screen use, and we need to normalize the use of screens. Parents themselves seem to experience challenges in their relationships to screens and may need to consider the impact of their screen-use messaging to their children. Specifically, autonomy support by democratically providing structure, open dialogue, and playful interaction between parents and children are necessary to help families improve relationships and resolve conflict as digital devices continue to shape our social world. --- Data Availability Statement: The data presented in this study are available on request from the corresponding author. The data are not publicly available because this is an ongoing five-year longitudinal study. --- --- Author Contributions: Conceptualization, K.F., H.S. and I.G.; methodology, K.F. and H.S.; formal analysis, K.F. and H.S.; investigation J.L. and T.H.; data curation, K.F., H.S., J.L. and T.H.; writingoriginal draft preparation, K.F.; writing-review and editing, all authors. All authors have read and agreed to the published version of the manuscript. Funding: This research was funded by European Research Council under the European Union's Horizon 2020 research and innovation program, grant number 683262. --- Institutional Review Board Statement: The study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the Institutional Review Board of Queens University (protocol code PSYC-181-16. Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.

Digital screens have become an integral part of everyday life. In the wake of the digital swell, pre-adolescents and their parents are learning to navigate seemingly new terrain regarding digital media use. The present study aimed to investigate parent and pre-adolescent perceptions of screen use and the source of conflict surrounding digital media. We employed a qualitative thematic analysis of 200 parent and pre-adolescent dyads discussing screen use. Our analysis showed five overarching themes for screen use perceptions and conflict: screen time, effects of screen use, balance, rules, and reasons for screen use. In contrast to previous studies that mainly focused on parental perceptions, we were also able to shed light on pre-adolescent perceptions of screen use and the difference in opinions with their parents. Furthermore, we found that patterns of the source of screen use conflict were oftentimes rooted in the age-old developmental tug of war between autonomyseeking pre-adolescents and authority-seeking parents. Though navigating autonomy-granting and seeking behavior is familiar to developmental scientists, negotiating these challenges in a new digital world is unfamiliar. Autonomy support, open dialogue, and playful interaction between parents and children are needed to understand and resolve conflict of digital media use in family contexts.